WELCOME TO THE 12TH ANNUAL CAMBRIDGE HEALTH ALLIANCE ACADEMIC POSTER SESSION
Tuesday, April 10 / 5:30 – 7:30 PM CHA Cambridge Hospital Healy Building
This signature CHA event is an opportunity for our community to share interests and accomplishments, and to forge new collaborations across departments and work sites. The session has grown over the years from a small Department of Medicine gathering to a CHA-wide event sponsored by the CHA Center for Professional and Academic Development. As you will see within these pages, the range of activity reflects a vibrant institutional commitment to research, innovation, continuous improvement and scholarship. We are grateful to the CHA Strategic Planning, Marketing & Communications Department and many others for their support of this event.
Elizabeth Gaufberg, MD, MPH Director, Center for Professional and Academic Development
David Bor, MD Chief Academic Officer
Maren Batalden, MD, MPH Associate Chief Quality Officer
Ellen Hedstrom Manager, Center for Professional and Academic Development TABLE OF CONTENTS
CASE STUDY AND CLINICAL RESEARCH PAGES 13–21
1. Use of Placental Grafts in 5. Big Five Personality Factors 8. The Relationship Between Foot and Ankle Surgery and Discordant Perceptions Interpersonal Problems Joel Ang, DPM, Surgery; of the Working Alliance and Working Alliance in David Liou, DPM, Surgery; Robert Drinkwater, PhD, Psychodynamic Therapy Harry Schneider, DPM, Surgery Program for Psychotherapy; Brandon Less; Ghita Jaouhari, Joseph Berlin, LCSW, Program Psychology; Katherine Chase, 2. Goblet Cell Carcinoid of for Psychotherapy; Julian PsyD, Psychology; Elisa Lee, the Appendix: A high grade Ernst, LCSW, Program for PhD; Meng-chun Chiang, tumor in a 20-year-old Psychotherapy; Shannon PhD; Adam Conklin, PhD, Ameen Barghi, MPP, CIC Mcintyre, PhD, Program for Psychology Student, Harvard Medical Psychotherapy; Rebecca School; John Grabbe, MD, Drill, PhD, Program for 9. Personal Distress Empathy Pathology; Arundhati Ghosh, Psychotherapy as a Component of MBBS, FRCS, FACS, Surgery Therapeutic Empathy 6. Patients’ View of Shannon McIntyre, PhD, 3. Collaborative Care: What is Most Helpful in Program for Psychotherapy; The Distress Thermometer Psychodynamic Treatment Lisa Wallner Samstag, PhD, as a Tool to Enhance Annabel Gill, LCSW, Psychology, Long Island Psychosocial Needs Psychiatry; Patrick Hunnicutt, University; Sara C. Haden, Assessment for CHA LCSW, Psychiatry; Hannah PhD, Psychology, Long Island Cancer Patients Richardson, PhD, Psychiatry; University; Joan W. Duncan, Dana Bogan, LCSW, Medicine; Laura Werner-Larsen, PhD, PhD, Psychology, Long Melanie Foxx, LCSW, Surgery; LICSW, Psychiatry; Jack Island University Heidi Rayala, MD, PhD, Surgery Beinashowitz, PhD, Psychiatry; Rebecca Drill, PhD, Psychiatry 4. The Role of Skin Biopsy in Calciphylaxis 7. The Neurobiology of Allison Dobry, MD, Mothering and Infant Stress Transitional Year Jennifer E. Khoury, PhD, Psychiatry; Grace Oh, BS, Psychiatry; Michelle Bosquet- Enlow, PhD, Psychiatry; Ellen Grant, MD, Psychiatry; Martin Teicher, PhD, MD, Psychiatry; Karlen Lyons-Ruth, PhD, Psychiatry
2 CEO CLER AWARDEES A small grants program for residents PAGES 23–34
10. A Hackathon to Target 16. Promoting Resilience Among 20. Providing Point of Care Missed Appointments in Women of Color in the CHA Access to Community Child Psychiatry Residency Program with a Resource Information Solomon Adelsky, MD, MPP, Dinner Seminar Series in a Primary Care Clinic Psychiatry; Nicholas Carson, Patrice Mann, MD, MPH, Courtney Scanlon, MD, MD, FRCPC, Psychiatry Psychiatry Family Medicine; Jennifer Panosian, MD, Family 11. Family Medicine 17. Social Justice Coalition’s Medicine; Tia Tucker, MD, Resident Workspace Home Series: A forum for Family Medicine; Racheli Danielle Antosh, MD, Family learning about the social Schoenburg, MD, Family Medicine; Jessica Platt, MD; determinants of health and Medicine; Emilie Biondokin, Jessica Early, MD; Lauren organizing around health MD, Family Medicine; Elzbieta Hoogewerff, MD; Randi Sokol, justice advocacy with Jacek, MD, Family Medicine; MD; Courtney Scanlon, MD trainees, faculty, and allies Sarah Bickerstaff, BS, Family in the CHA community Medicine 12. Screening and Referral for James B. McKenzie, DO, MBA, Food Insecurity in a Child Psychiatry; Carrie C. Wu, MD, 21. Impact and Perceptions of and Adolescent Psychiatry Psychiatry Teledermatology at CHA Outpatient Clinic Robert Stavert, MD, Shireen Cama, MD, Psychiatry; 18. Sports Skills and Dermatology; Tedi Begaj, Lee Robinson, MD, Psychiatry Nutrition Day: Promoting MD, Internal Medicine; Allison Exercise & Healthy Eating Dobry, MD, Internal Medicine; 13. Caring for Our Communities: in Female Youth Rebecca Droms, MD, Internal Improving Behavioral Health Chukwueloka Obionwu, MD, Medicine; Sumi Sinha, MD, Care for LGBTQ+ Latino Family Medicine; Dominic Internal Medicine Populations Wu, MD, Family Medicine; Daniel A. Gonzalez, MD, Sarah Bickerstaff, BS, Family 22. Antimicrobial Susceptibility Psychiatry Medicine; Jessica Knapp, DO, Among Uropathogens CAQSM, Family Medicine Causing Acute Uncomplicated 14. Outmigration of CHA Patients Cystitis at Cambridge for ED and Inpatient Care 19. “A Vida Doce” Improving Health Alliance Shirin Karimi, MD, Medicine Self-Management Skills of Frances Ue, MD, MPH, Portuguese-Speaking Patients Internal Medicine; Rebecca 15. Understanding the Needs of with Diabetes Mellitus Osgood, MD, Pathology; the Latino Population in a Krupa Parikh, MD, Internal Lou Ann Bruno-Murtha, DO, Pediatric/Behavioral Health Medicine; Sonja Skljaverski, Infectious Diseases Integrated Care Service MD, Internal Medicine; Aileen Lorenzo, MD, Psychiatry Nicole Mushero, MD, Internal Medicine; Yamini Saravanan, MD, Internal Medicine
3 COMMUNITY HEALTH AND HEALTH POLICY PAGES 35–48
23. A State-Level Report Card on 25. The Impact of the Affordable 27. 2015-2017 CHA Cancer the Impact of the Affordable Care Act on Coverage and Community Needs Care Act on Insurance Access on Americans with Assessment: Comparing Coverage for Racial and Cardiovascular Disease or Demographics of CHA Panel Ethnic Minorities and Multiple Cardiovascular Patients who are Screened vs Low-Income Americans Risk Factors Not Screened for Colorectal, Lynn Anderson, MD, Medicine; Ameen Barghi, MPP, CIC Cervical, and Breast Cancer Erica C. Dwyer, MD, PhD, Student, Harvard Medical Taisha Joseph; Sarah Primeau, Medicine; Megan LaPorte, School; Hugo Torres, MD, MPH, MSW, MPH, Community MD, Medicine; Deborah Medicine; Nancy R. Kressin, Health Improvement; Rumel Lee, MD, Medicine; Gregory PhD, BU School of Medicine; Mahmood, Quality and Patient Lines, MD, MPH, Medicine; Danny McCormick, MD, MPH, Safety; Karen Finnegan, Kira Mengistu, MD, Medicine; Medicine Institute for Community Daniel Novinson, MD, MPH, Health; Heidi Rayala, MD, Medicine; Sonja Skljarevski, 26. The Power of Collaboration: PhD, Surgery MD, Medicine; Gaurab Basu, Strengthening the CHA MD, MPH, Medicine; Danny partnership with Malden 28. Changes in Psychiatric McCormick, MD, MPH, Public Schools Title I program Emergency Room Medicine; Hugo Torres, MD, for community benefit Visits Following the MPH, Medicine Devorah Donnell, MD, Family Boston Bombing Medicine; Renée Cammarata Gaddy Noy, DO, Psychiatry; 24. Assessing the Impact of a Hamilton, MSW, MPA, CHA Amber Frank, MD, Psychiatry Worksite Wellness Initiative Health Improvement; Paul on Employee Engagement McCarthy, Malden Public Carolyn Ballard, MS, RD, Schools Title 1 Parent Human Resources; Sharon Coordinator Touw, MPH, Institute for Community Health; Elaine Zhang, BS, Institute for Community Health
4 COMMUNITY HEALTH AND HEALTH POLICY (CONTINUED) PAGES 35–48
29. See, Test and Treat: 31. Differences in Rates of 33. A Tale of Three Projects: A Program that Fulfills Suicidal Ideation and Co-Production as an the Cambridge Health Potential Suicide Attempt Approach to Health Alliance Mission Among Disabled and Systems Transformation Rebecca Osgood, MD; Kate Gender Minority Medicare Martina Todaro, MPA, Institute Harney, MD; Sarah Primeau, Beneficiaries from 2009-2014 for Community Health; MSW, MPH, Community Health Ana Progovac, PhD, Health Maren Batalden, MD, MPH, Improvement; Megan Meany, Equity Research Lab; Brian Performance Improvement; CHA Foundation; Bonnie Mullin, Health Equity Research Ann Hwang, MD, Community Martin, Marketing; Alexis Ladd, Lab; Maria Jose Sanchez, Catalyst; Carolyn Fisher, PhD, Marketing; Mary Cassesso, MD, Health Equity Research Institute for Community Health CHA Foundation Lab; Alex McDowell, MPH, MSN, Harvard University; Sari 34. Acknowledging the Role of 30. ACE Assessment in Clinical Reisner, ScD, Harvard Medical Fathers: The experience of Practice: A Pediatric School; Emilia Dunham, MBA, a local parenting program Integrated Care Model MPP; Cynthia Telingator, MD; Sharon Touw, MPH, Institute Priya Pathak, BSc, MD Benjamin Le Cook, PhD, MPH, for Community Health; Shawn Candidate; Katherine E. Health Equity Research Lab Proctor, BS, City of Cambridge Grimes, MD, MPH, Psychiatry Center for Families; Abigail 32. Inpatient Medicaid Cost and Tapper, MPH, Institute for Utilization Patterns After Community Health Changes in Supplemental Nutrition Assistance Program Benefit Levels Rajan Sonik, PhD, JD, MPH, Psychiatry
5 COMMUNITY HEALTH AND HEALTH POLICY (CONTINUED) PAGES 35–48
35. Evaluation of CHA’s Complex 36. Reducing Childhood Obesity: Care Management Program Promoting Exercise and Greg Watt, MSW, Primary Care Healthy Eating Complex Care Management; Dominic Wu, MD, Family Sharon Touw, MPH, Institute Medicine; Chukwueloka for Community Health; Obionwu, MD, Family Medicine; Nicholas Cone, Primary Care Sarah Bickerstaff, BS, Family Complex Care Management; Medicine; Jessica Knapp, DO, Karen Finnegan, MPH, Institute CAQSM, Family Medicine for Community Health; Kristin King, MPPM, Institute for 37. Immigrants Contributed Community Health; Leah $27.9B More to Private Zallman, MD, MPH, Institute for Insurers Than They Took Community Health; Eleni Carr, Out in 2014 MBA, LICSW, Accountable Leah Zallman, MD, MPH, Care Organization Institute for Community Health; Steffie Woolhandler, MD, MPH, City University at Hunter College; Sharon Touw, MPH, Institute for Community Health; David Himmelstein, MD, City University at Hunter College; Karen Finnegan, MPH, Institute for Community Health
6 HEALTH PROFESSIONS EDUCATION PAGES 49–53
38. Teaching Medicine Interns 40.Innovation in a Safety-Net 42. Developing a “Wellness Minimum Geriatrics Hospital: Building a point-of- Space” to Enhance Our Competencies within care ultrasound curriculum Culture of Wellness a “4 + 2” Schedule through a resident-led, Meera Sunder, MD, Kanthi Serena Chao, MD, MSc, low-resource model Dhaduvai, MD, Andrea Geriatrics Division; Anne Kay Negishi, MD, Internal Gordon, MD, Family Medicine Brouha, MD, Geriatrics Division; Medicine; John DeAngelis, MD, Rachel Stark, MD, Medicine RDMS, Emergency Medicine; Jonathan Opraseuth, MD, 39. Diagnosing the Learner: An Radiology; Priyank Jain, MD, analysis of how our learners Internal Medicine are clinically reasoning Rachel Hathaway, MD, 41. Generating Best Medicine; Michael McShane, Precepting Practices MD MEd, Medicine; Hugo through a Collaborative, Torres, MD, MPH, Medicine; Multi-Disciplinary Faculty David Scales, MD, PhD, Development Workshop Medicine; Priyank Jain, MD, Tara Singh, MD, OBGYN; Medicine; Joshua Onyango, Bianca Shagrin, MD, Pediatrics; MS, Harvard Graduate School Yamini Saravanan, MD, of Education; David Cameron, Internal Medicine BU School of Public Health; Richard Pels, MD, Medicine
7 QUALITY/SYSTEMS IMPROVEMENT PAGES 55–76
43. Practice Improvement 45. What are Families Looking 47. Meaningful Wait Times: Teams: Fostering Leadership for in an Integrated Mental Improving the Patient and Performance Health Care Experience Perception of Care and Improvement Training at CHA? Quality Outcomes Within a Clinical Practice Nicholas Carson, MD, Gilberto Gamba, MS, BSN, Fa’iz Bayo-Awoyemi, MD, Psychiatry; Lee Robinson, MD, RN, Primary Care Nursing Family Medicine; Dominic Psychiatry; Traci Brooks, MD, Wu, MD, Family Medicine; Pediatrics; Aileen Lorenzo, 48. Decreasing Short Term Rehab Christina Norton, Family MD, Psychiatry; Brenda Utilization in a PACE Program Medicine; Lucretia Fitzpatrick, Marin-Rodriguez, BSc, Mary Ann Graham, MS, RD, Family Medicine; Stephen Crimson Care Collaborative; LDN, Elder Service Plan; Dolat, BS, MBA, Primary Care; Keval Vyas, BEng, Crimson Janet Dunphy, RN, CCM, Elder Susan Morrissey, BSN, MS, Care Collaborative; Ifigenia Service Plan; Christopher Family Medicine; Gouri Gupte, Mougianis, PhD, Psychiatry Mauro, LICSW, Elder Service PhD, MHA, Performance Plan; Jonathan Burns, MD, Improvement; Paola Peynetti 46. Reducing Avoidable ER Elder Service Plan; Jed Velasquez, MPH, Performance Visits in CHA House Calls Geyerhahn, Elder Service Plan; Improvement; Judy Fleishman, Patients with Dementia Norma Malkiel, LSW, CCM, PhD, Family Medicine; Nicole Serena Chao, MD, MSc, Elder Service Plan O’Connor, MD, Family Medicine Geriatrics Division; Karen Finnegan, MPH, Institute for 44. Cahill 4 Unit Based Council: Community Health; Deborah Transforming Care With Lee, MD, Medicine; Carolyn Relationship Based Care Fisher, PhD, Institute for Versa E. Belton, RN, MSN, Community Health; Daphne NEC-BC Schneider, MD, Geriatrics Division
8 QUALITY/SYSTEMS IMPROVEMENT (CONTINUED) PAGES 55–76
49. Group Wellness Classes 51. Medication Reconciliation 53. Solving the Mystery of Among CHA’s Haitian and Optimization by Clinical Unsatisfactory PAP Smears Patients: Lessons Learned Pharmacists in the Primary Rebecca Osgood, MD, and Future Directions Care Setting Pathology and Clinical Anand Habib, MPhil, Harvard Alexandra Kolwicz, PharmD, Laboratories; John Grabbe, MD Medical School; Shalini Pharmacy; Catrina Derderian Chalana, MS, MEd, RD, LDN, PharmD, BCACP, Pharmacy; 54. Reducing Utilization CDE, Medicine; Arlene Katz, Emily Zouzas, PharmD, of Unsafe Practices for EdD, Department of Global BCACP, Pharmacy; Monica Communicating with Limited Health and Social Medicine; Akus, PharmD, BCPS, DPLA, English Proficient Patients Marie-Louise Jean-Baptiste, Pharmacy; Robin Heafey, Ranjani Paradise, PhD, ICH; MD, Medicine PharmD, BCACP, Pharmacy Megan Hatch, MPH, ICH; Avlot Quessa, BA, JD candidate, 50. Impact of Multitiered 52. HFMEA Analysis of MAPS; Vonessa Costa, Interventions to Decrease Medication Errors in CoreCHI, MAPS; Fernando Routine Urine Cultures in a PACE Program Gargano, MAPS Asymptomatic Patients Lorraine Murphy, MS, RN, Undergoing Hip and Knee Quality & Risk Management; Arthroplasty Mary Ann Graham, MS, RD, Ebony Jackson, PharmD, LDN, Elder Service Plan; Pharmacy; Amanda Barner, Janet Dunphy, RN, CCM, PharmD, BCPS, Pharmacy; Elder Service Plan; Jonathan Xia Thai, PharmD, Pharmacy; Burns, MD, Elder Service Lou Ann Bruno-Murtha, DO, Plan; Michelle Ortiz, RPH, Infectious Disease Elder Service Plan Pharmacy; Emerenziana D’Alleva, RPh, BCGP
9 QUALITY/SYSTEMS IMPROVEMENT (CONTINUED) PAGES 55–76
55. Improving Access to Adult 56. Improving Access to Child 57. Improving the Phone Outpatient Psychiatry at and Adolescent Outpatient Menu Across Cambridge Cambridge Health Alliance Psychiatry at Cambridge Health Alliance Paola Peynetti Velazquez, Health Alliance Paola Peynetti Velazquez, MPH, Performance Paola Peynetti Velazquez, MPH, Performance Improvement; Gouri Gupte, MPH, Performance Improvement; Gouri Gupte, PhD, MHA, Performance Improvement; Gouri Gupte, PhD, MHA, Performance Improvement; Edgardo Trejo, PhD, MHA, Performance Improvement; Fernando MD, Psychiatry; Lisa Foley, Improvement; Jacob Venter, Gargano, Multicultural MPA, Psychiatry; Michael MD, MBA, Psychiatry; Lisa Affairs and Patient Services; Williams, LICSW, Psychiatry; Foley, MPA, Psychiatry; Michael MaryAnn Heuston, MA, Mark Albanese, MD, Psychiatry; Williams, LICSW, Psychiatry; Revenue Cycle Access Page Carter, LICSW, Psychiatry; Nicholas Carson, MD, Operations; Avlot Quessa, Julie Regner, Psychiatry; Emily Psychiatry; Dianna Lesanto, Multicultural Affairs and Patient Benedetto, MSW, LCSW, LICSW; Assaad Sayah, MD, Services; Vonessa Costa, Primary Care; Ellie Grossman, Chief Medical Officer; Multicultural Affairs and Patient MD, Primary Care; Colleen Renee Kessler, MHA, Chief Services; Paola Held, MEd, O’Brien, PhD; Assaad Sayah, Operating Officer Revenue Cycle Operations; MD, Chief Medical Officer; Steven Dolat, MBA, Primary Renee Kessler, MHA, Chief Care Operations; Patrick Operating Officer Wardell, MBA, Chief Executive Officer; Renee Kessler, MHA, Chief Operating Officer
10 QUALITY/SYSTEMS IMPROVEMENT (CONTINUED) PAGES 55–76
58. Implementing Addiction 61. A Quality Improvement 63. Planning Together: Services Into Primary Care Project: Better Substance Care Planning to Improve Debralee Quinn, MSN, RN-BC, Use Screening for Patient Activation and CNN, CH-GCN, CCM, Cambridge Students Health Outcomes Primary Care Tali Schiller, MPH, Cambridge Miriam Tepper, Psychiatry; Public Health Department; Ekta Taneja, Psychiatry; 59. Improving the Mammography Kristin Ward, MPH, Cambridge Alexander Cohen, Psychiatry; Workflow in the Radiology Public Health Department; Martha Barbone Department at Cambridge Tracy Rose-Tynes, BSN, RN, Health Alliance Cambridge Public Health 64. Cost-Savings of Long-Acting Aliysa Rajwani, BDS, MPH; Department; Mary Kowalczuk, Antipsychotic Injections in a Gouri Gupte, PhD, MHA; MSW, Cambridge Public Transitional Outpatient Clinic Mary Kearns, RN, Quality Health Department Upon Hospital Discharge Management; Leah Harrington; Rebecca Tourtellotte, PharmD, Hetal Verma, MD; Doris 62. CHA Broadway Health Care Pharmacy; Jessica Goren, Gentley; Carol Hulka, MD, Proxy Improvement Project: PharmD, BCPP, Pharmacy Radiology A Multi-Layered Approach Arshiya Seth, Medicine; 60. Colorectal Cancer at CHA: Maria Terra, Medicine; 10-Year Comparison of Priyanka Anand, Performance CHA with National Cancer Improvement; Jesenia DataBase (NCDB) and an Bermudez, Broadway Care In-Depth Review of 2016 Center; Rina Bernardez, CHA Colorectal Patients Broadway Care Center; Betsy Heidi Rayala, MD, PhD, Surgery; Doucette, Broadway Care Mary Kearns, Quality & Patient Center; Wilkerson Elysee, Safety; Richard Swanson, MD, Broadway Care Center; FACS, Surgery Meredith Jones, Broadway Care Center; Dierdre Jordan, Broadway Care Center; Denise Leite Alves, Broadway Care Center; Mary Saginario; Robert Smith, LPN, Broadway Care Center; Maria Sousa
11 QUALITY/SYSTEMS IMPROVEMENT (CONTINUED) PAGES 55–76
65. An Interdisciplinary Practice 66. Can We Improve Provider Improvement Team: Engagement Through Clinic Workflow Design Co-Production? Dominic Wu, MD, Family Leah Zallman, Bree Dallinga, Medicine; Fa’iz Bayo-Awoyemi, Joy Curtis, Marcy Lidman, MD, Family Medicine; Gouri David Porell, Assaad Sayah Gupte, PhD, MHA, Performance on behalf of the Provider Improvement; Paola Peynetti Engagement Steering Velasquez, MPH, Performance Committee Improvement; Christina Norton, Family Medicine; 67. Impact of Medical Scribes Lucretia Fitzpatrick, Family on Productivity, Face-to-Face Medicine; Rumel Mahmood, Time and Patient Comfort MA, MS, Business Data with Scribes in Primary Care Analysis; Susan Morrissey, BSN, Leah Zallman, MD, MPH, MS, Family Medicine; Stephen Institute for Community Health; Dolat, BS, MBA, Primary Karen Finnegan, MPH, Institute Care; Lora Council, MD, MPH, for Community Health; David Primary Care; Jill Batty, BS, Roll, MD, Medicine; Martina MHA, Finance; Jessica Knapp, Todaro, MA, Institute for DO, CAQSM, Family Medicine; Community Health; Rawan Judy Fleishman, PhD, Family Oneiz, MD; Assaad Sayah, MD, Medicine; Nicole O’Connor, MD, Chief Medical Officer Family Medicine
12 ABSTRACTS
CASE STUDY AND CLINICAL RESEARCH
Use of Placental Grafts in Introduction: Viable cryopreserved amniotic grafts have long Foot and Ankle Surgery been utilized in the realm of wound care. Recently, these grafts have started to be implanted within the foot and ankle to facilitate Author(s): healing through decreasing inflammation, preventing adhesion, Joel Ang, DPM, Surgery; and promoting tissue growth. Currently, there is limited literature David Liou, DPM, Surgery; regarding complications of graft application in foot and ankle Harry Schneider, DPM, Surgery surgery. This case series examines patients who have received viable cryopreserved grafts and surveys for any post-operative POSTER 1 complications.
Case Description: A chart review at Cambridge Health Alliance was performed for patients who received viable cryopreserved amniotic grafts for surgical rearfoot and ankle procedures since 2015. Ten patients fit the inclusion criteria. A wide variety of surgical interventions were performed—three primary tendon repairs, three tarsal tunnel releases, one calcaneonavicular coalition resection, one peroneal tendon tenolysis, one scar tissue resection, and one excision of multiple plantar fibromas. Of the ten patients, only one had a notable post-operative complication. This patient underwent an extensive excision of multiple plantar fibromas on the left foot, with subsequent cellulitis. Through local wound care, and oral antibiotics, surgical site healed without sequelae.
Discussion: The one post-operative complication noted was likely secondary to the size and location of the initial incision. Based on this small case series, the implantation of viable cryopreserved amniotic tissue in the foot and ankle seems safe. Though the current literature regarding viable grafts is scarce, the findings are consistent with the available published case reports.
CASE STUDY AND CLINICAL RESEARCH 13 Goblet Cell Carcinoid of the Introduction: The goblet cell carcinoid (GCC) is a rare appendiceal Appendix: A high grade tumor tumor of the appendix that typically presents in the fifth or sixth in a 20-year-old decade of life. The age-adjusted annual incidence of all appendiceal tumors is 0.12 cases per 1,000,000. The histologic hallmark of this Author(s): entity is the presence of clusters of goblet cells in the lamina propria Ameen Barghi, MPP, CIC or submucosa stain for various neuroendocrine markers. Due to its Student, Harvard Medical School; grave prognosis, GCC is surgically treated as an adenocarcinoma, John Grabbe, MD, Pathology; with right hemicolectomy as the mainstay of treatment. Arundhati Ghosh, MBBS, FRCS, FACS, Surgery Presentation of Case: We report a case of a 20-year-old male who presented with acute lower quadrant pain symptoms seemingly POSTER 2 consistent with acute appendicitis. He was diagnosed with a high grade GCC that encompassed his entire appendix post uncomplicated laparoscopic appendectomy.
Discussion: GCC is a rare tumor of the appendix with unique histological features. It is often retroactively diagnosed with histology after a majority of patients present with acute appendicitis symptoms. The behavior of this tumor in pediatric-young adults is very poorly understood. Still the exact biological behavior of this tumor is uncertain.
Conclusion: We review the literature for GCC of the appendix and illustrate a case report of a young, otherwise healthy 20-year-old who presented as appendicitis. We conclude that when offering non- operative management of acute appendicitis, incidental malignancy must be kept in mind.
14 Collaborative Care: Introduction: For patients diagnosed with cancer, there can be The Distress Thermometer as a significant psychosocial stressors that are not directly associated Tool to Enhance Psychosocial with their medical care. In 2015, CHA adopted the use of the well Needs Assessment for CHA validated “Distress Thermometer” (DT) to evaluate the psychosocial Cancer Patients needs of our cancer patients. All patients undergoing cancer care at CHA complete the DT, which includes a self-reported overall stress Author(s): score on a 0-10 scale, as well as a problem checklist with 35 individual Dana Bogan, LCSW, Medicine; issues. Patients scoring four or more are referred to our social work Melanie Foxx, LCSW, Surgery; team for further assessment and intervention. Heidi Rayala, MD, PhD, Surgery Summary of Findings: We reviewed all DT responses from its POSTER 3 inception at CHA in 2015 until November 2017. There were a total of 418 surveys completed. The average DT overall score was 4.39. 56.8% of CHA patients reported a score of four or more, significantly more than the 43% previously published in US literature. The most commonly endorsed categories were Emotional Problems, Physical Problems, and Practical Problems, endorsed by 33.6%, 17.5%, and 9.2% of patients, respectively.
Discussion and Future Direction: Following the data analysis, we identified Financial Distress as one that poses a significant challenge to patients undergoing cancer care and also has limited resources. To address this, we have created the CHAmpion fund to help with living expenses for our patients undergoing cancer care. We also found the current DT to have limitations on evaluating the impact of financial burden. Future goals are to develop a more refined DT for financial and practical concerns.
CASE STUDY AND CLINICAL RESEARCH 15 The Role of Skin Biopsy Calciphylaxis is an ulcerative skin disease with high mortality in Calciphylaxis that typically requires multidisciplinary management. Although calciphylaxis can be histopathologically confirmed by skin biopsy, Author(s): the necessity of a biopsy as a prerequisite for diagnosis is debated. Allison Dobry, MD, A positive biopsy helps exclude mimics of calciphylaxis and avoids Transitional Year unnecessary treatment. However, it is thought that skin biopsy carries low sensitivity and may lead to further areas of necrosis or POSTER 4 superimposed infection in this patient cohort. To further examine these concerns, retrospective chart review was performed on 68 patients with biopsy-proven calciphylaxis. Initial biopsy was positive in 35 patients, conferring a sensitivity of 52.2%. Forty-two patients (62.7%) required multiple biopsies until a positive diagnosis (median number 2, range 1-9). Median time from onset of calciphylaxis lesions to positive biopsy was 71 days (range 2-496). The percentage of patients started empirically on IV sodium thiosulfate prior to positive biopsy was 22.7%. A positive biopsy led to change in therapy in 60.0% of patients. Of those that were biopsied, 28.6% of patients suffered from complications, including further necrosis, poor healing, or infection. Overall, biopsies led to therapy change in a majority of patients, but have a low sensitivity and led to complications in almost one-quarter of patients. Interestingly, empiric therapy was often recommended by dermatologists but held due to requests for positive biopsy from nephrology or from patients’ insurance. Providers should think carefully about the health status of a patient prior to decision to biopsy and more frequently consider empiric treatment based on clinical diagnosis alone.
16 Big Five Personality Factors The clinical utility of the construct of the working alliance is well and Discordant Perceptions established in psychotherapy literature, but little research exists of the Working Alliance examining the relationships between patient and therapist views of the alliance (concordance/discordance), and the factors that may lead Author(s): to discordant views of the alliance. The present study aims to examine Robert Drinkwater, PhD, the influence of the “Big 5” personality factors on discordance Program for Psychotherapy; between therapist and patient ratings of the working alliance. The Joseph Berlin, LCSW, Program study’s sample is drawn from patients and therapists meeting in a for Psychotherapy; Julian two-year psychodynamic psychotherapy training program. Participant Ernst, LCSW, Program for responses to the Combined Alliance-Short Form (CASF) (both the Psychotherapy; Shannon Patient Version and Therapist Version) and the Ten Item Personality Mcintyre, PhD, Program for Inventory were used to measure working alliance and patient Psychotherapy; Rebecca Drill, personality factors, respectively. The present study hypothesizes PhD, Program for Psychotherapy that where there is not concordance (i.e., there is discordance) between therapists’ and patients’ ratings, patients’ personality traits POSTER 5 will be a contributing factor; in other words, personality factors of the patient will influence concordance of perception of working alliance between patient and therapist (with personality trait being the mediator). Specifically, this study hypothesizes that patients who are rated low on openness to experience, low in agreeableness, high in neuroticism, high in conscientiousness, and low in extroversion will be associated with greater discordance in patient and therapist ratings of the working alliance. This study would make a significant contribution to therapists’ capacity to make ongoing assessments of the working alliance, as mutually constituted by the perceptions of both participants in the therapeutic dyad.
CASE STUDY AND CLINICAL RESEARCH 17 Patients’ View of What Introduction: In meta-analyses, psychodynamic psychotherapy is is Most Helpful in shown to be at least as effective as CBT in symptom relief (Barber Psychodynamic Treatment et al., 2013; Shedler, 2010), with some evidence of longer-lasting gains. There are theories about what makes psychodynamic therapy Author(s): effective, but little is known empirically. Annabel Gill, LCSW, Psychiatry; Patrick Hunnicutt, LCSW, Objectives: This mixed methods study examines the treatment Psychiatry; Hannah Richardson, factors that patients identify in their own words as most helpful. PhD, Psychiatry; Laura It draws from a sample of diverse patients, many with comorbidities, Werner-Larsen, PhD, LICSW, who receive psychodynamic therapy in a public hospital. Psychiatry; Jack Beinashowitz, PhD, Psychiatry; Rebecca Methods: This project is a naturalistic, longitudinal study conducted Drill, PhD, Psychiatry at a public hospital. Participants were seen weekly for up to two years and are were asked to complete surveys every 3-6 months. POSTER 6 The current study examines 99 responses to an open-ended question at the three-month follow-up: “What do you find most helpful about the treatment you are currently receiving?” The authors use modified grounded theory methods (Glazer & Strauss, 1967) to develop a customized coding scheme based on participants’ responses to this question, and analyze the data according to this scheme.
Results: Due to inadequate reliability in the first iteration of our coding scheme, we have restructured the code book and modified or discarded codes with poor reliability. Results based on this scheme will be forthcoming.
Discussion: The study’s goal is to better understand what works in psychodynamic therapy to improve interventions. It broadens the scope of early research by examining the perspectives of a diverse group of patients. Obstacles encountered during this project as well as directions for future research will be discussed.
18 The Neurobiology of Background: Childhood maltreatment has adverse effects on Mothering and Infant Stress neurobiology and later parenting. No studies have explored how adversity-related changes in the human parental brain are involved in Author(s): pathways to parental stress and disrupted parent-infant interaction, Jennifer E. Khoury, PhD, with associated impact on the infant’s stress response and neurobiology. Psychiatry; Grace Oh, BS, This multi-site NICHD-funded study will evaluate these pathways. Psychiatry; Michelle Bosquet- Enlow, PhD, Psychiatry; Ellen Methods: The study will include 120 mother-infant dyads, 50 assessed Grant, MD, Psychiatry; Martin in pregnancy, and all assessed at infant ages four and 15 months. Teicher, PhD, MD, Psychiatry; We assess maternal psychopathology and maltreatment history via Karlen Lyons-Ruth, PhD, questionnaires/interviews. Maternal stress functioning is assessed Psychiatry via cortisol collected from hair. At four and 15 months, mothers and infants complete standardized stressor protocols (Still-Face POSTER 7 Procedure, Strange Situation), during which maternal behaviors are coded and maternal and infant cortisol reactivity are assessed (Dr. Lyons-Ruth, Cambridge Hospital). Mothers and infants complete MRI procedures (Dr. Teicher, McLean Hospital; Dr. Grant, Boston Children’s Hospital).
Results: To date, 36/50 mothers have completed the prenatal visit, 72/120 mother-infant dyads the four-month visit, and 24/120 mother-infant dyads the 15-month visit; 21 infants and 47 mothers have completed the MRI procedures. This sample includes 45% male infants; maternal age M=31.67 (SD=4.2) years. Among mothers, 47.5% reported experiencing childhood maltreatment, 5.7% endorsed clinical symptoms of depression, and 8.3% clinical symptoms of PTSD. Hair cortisol during pregnancy is correlated with physical domestic assault (r =.43, p <.05), and shows medium effect sizes in association with childhood physical abuse (r = .28, p =.13) and physical neglect (r = .25, p =.18).
Conclusions: By combining developmental science and neurobiology, this research will provide novel insights into the neurobiological factors mediating links between early maltreatment and subsequent disturbances in the parent-infant relationship.
CASE STUDY AND CLINICAL RESEARCH 19 The Relationship Between Aim: As part of an effort to evaluate patient treatment outcomes Interpersonal Problems within the Psychodynamic Research Clinic (PRC), empirically and Working Alliance in validated measures were administered to patients at specific time Psychodynamic Therapy points throughout the psychotherapy process to investigate two separate questions: (1) are patient reported interpersonal problems Author(s): at the beginning of therapy predictive of stronger working alliance, Brandon Less; Ghita Jaouhari, and (2) are stronger patient reported post-treatment working alliance Psychology; Katherine Chase, predictive of greater symptom reduction at the end of therapy. PsyD, Psychology; Elisa Lee, PhD; Meng-chun Chiang, PhD; Adam Measures: The Inventory of Interpersonal Problems (IIP-32) is a Conklin, PhD, Psychology 32-item self-report measure of interpersonal problems. The Brief Symptoms Inventory (BSI) is a 53-item self-report symptom scale. POSTER 8 The Working Alliance Inventory-Patient (WAI-P) is a 36-item, self-report patient measure of therapeutic alliance.
Procedure: The current study will include data from patients who participated in the PRC between 2014 and 2017 (N = 47), receiving a range of two to 11 months of treatment. The relationship between IIP-32 total scores, collected at intake, and total WAI-P scores, obtained at the end of treatment, will be examined through regression analyses. ANOVA analyses will be used to examine the relationship between WAI-P alliance assessed at the end of the treatment and change in Global Severity (mean item-score) on the BSI over the course of treatment.
Findings: Our research team is in the process of analyzing the data collected.
20 Personal Distress Empathy Research suggests that therapeutic empathy is the key determinant as a Component of of outcome in psychotherapy (e.g., Greenberg et al., 2001), yet there Therapeutic Empathy does not appear to be one standardized definition. Relational theories offer an integrated construct, called the empathic process, which Author(s): consists of both “feeling into” states of emotional resonance with the Shannon McIntyre, PhD, Program patient’s experience, and “feeling out of” such states by regaining for Psychotherapy; Lisa Wallner one’s emotional balance (Beuchler, 2008). Yet, researchers have Samstag, PhD, Psychology, Long tended to dismiss forms of interpersonal reactivity that Batson et al. Island University; Sara C. Haden, (2005) found to be “self-oriented” (i.e., personal distress empathy, PhD, Psychology, Long Island or the tendency toward discomfort upon hearing another’s plight), University; Joan W. Duncan, in favor of those that Batson et al. found to be “other oriented” PhD, Psychology, Long Island (i.e., warmth and compassion) (e.g., Hassenstab et al., 2007; Hatcher University et al., 2005). To test the hypothesis that personal distress empathy serves an adaptive function for therapists, self-report measures were POSTER 9 administered to a sample of 135 therapists and 147 non-therapists. Results indicated that the fear of invalidity (i.e., self-doubt) explained the relationship between preoccupied attachment and personal distress empathy among those with less therapist experience, though not among those with more. Higher therapist experience level was also associated with lower personal distress empathy among those with two years of weekly therapy or less. Alternatively, among those with many years of therapy, higher therapist experience level was associated with higher personal distress empathy. These results suggest that personal distress empathy—when felt by experienced, well-analyzed therapists—serves as a mechanism of change, within a larger empathic process.
CASE STUDY AND CLINICAL RESEARCH 21 ❱ 2018 Academic Poster Session by the Numbers
Health Professions Education (5)
Community Health and Health Policy (15) Quality and Systems Improvement (25)
CEO CLER AWARDEES (13)
Case Study and Clinical Research (9)
22 CEO CLER AWARDEES Cambridge Health Alliance CEO Patrick Wardell, in collaboration with the Arnold P. Gold Foundation, supports the Clinical Learning Environment Review (CLER) Innovation Grants Program. All graduate-level trainees in CHA-sponsored programs are eligible to apply for up to $3,000 of grant funding annually to develop initiatives that will improve both the patient experience of care and the staff experience of caring.
A Hackathon to Target Background: From July-December of 2016, 67.9% of 2,995 visits to Missed Appointments the child psychiatry outpatient department at Cambridge Health in Child Psychiatry Alliance were completed. A one-day trainee-led hackathon (rapid- design improvement event) utilizing principles from human-centered Author(s): design, was planned and executed. Solomon Adelsky, MD, MPP, Psychiatry; Nicholas Carson, MD, Description of the problem in context at CHA: 25% of visits were FRCPC, Psychiatry no-shows or cancelled by patient. Missed appointments result in decreased access to care, reduced quality of care, lost revenue, POSTER 10 and inferior quality of education for trainees.
Change ideas and implementation: To hold a rapid-design improvement event to spark innovative approaches to reducing missed appointments.
Results/outcomes: A multidisciplinary team was assembled including patients, referral coordinators, an interpreter, and clinicians. Over 100 unique ideas were generated, many of which are being implemented or engaged in PDSA (Plan-Do-Study-Act) cycles. Hackathon participants reported an increase in a variety of self- efficacy measures including empowerment to suggest improvements, confidence regarding analyzing institutional challenges, inspiration to create change, and likeliness to suggest changes to reduce missed appointments.
Implications/lessons learned: A one-day, rapid-design improvement event can be an effective approach to tackling a difficult institutional challenge. Challenges involved in such an approach include maintaining momentum, executing plan-do-study-act cycles, and continuing to incorporate the perspective of patients throughout the improvement process.
CEO CLER AWARDEES 23 Family Medicine Resident The Residency Improvement Team at the Tufts University Family Workspace Medicine Residency at Cambridge Health Alliance is proposing to create a Family Medicine Resident Wards Workspace. Our aim is to Author(s): provide a safe and secure space for residents to work together to Danielle Antosh, MD, Family provide team-based care for patients in the inpatient setting. Having Medicine; Jessica Platt, MD; a dedicated space on the West 1 floor of CHA Everett Hospital will Jessica Early, MD; Lauren increase collaboration with other care providers including nursing Hoogewerff, MD; Randi Sokol, staff, increase patient safety with providers being closer to patient MD; Courtney Scanlon, MD rooms, and create a sense of community amongst residents while providing a functional workspace with adequate computer access. POSTER 11 This space will provide a location to more easily discuss patient plans with the team, help with task completion, increase timeliness of communication, and increase direct supervision of residents. We plan to measure change as an improvement by collecting feedback from residents, attendings and nursing staff on the following measures: access to computers, teamwork and communication, and how often the space is used.
24 Screening and Referral for Research has shown that over one-third of yearly deaths in the Food Insecurity in a Child United States can be accounted for by societal factors including and Adolescent Psychiatry poverty, poor education and social supports. Screening for social Outpatient Clinic determinants of health is becoming increasingly emphasized in both adult and pediatric medical settings. As psychiatrists, we are Author(s): taught to think about the social factors that affect our patients, yet Shireen Cama, MD, Psychiatry; we often struggle to know how best to address them. My project is Lee Robinson, MD, Psychiatry a QI initiative designed to increase screening for food insecurity at the Child Psychiatry OPD and refer positive screens to a community POSTER 12 food organization. Data including the number of positive screens and referral outcomes will be shared.
CEO CLER AWARDEES 25 Caring for Our Communities: Individuals with stigmatized identities experience minority stress, Improving Behavioral Health which refers to the health effects of stigma and prejudice on Care for LGBTQ+ Latino marginalized communities. Research has shown that minority stress Populations contributes to the development and severity of the following health conditions: depression, anxiety, asthma, heart disease, physical Author(s): and psychological disability, and suicide risk. Resilience among Daniel A. Gonzalez, MD, vulnerable patient populations experiencing minority stress has been Psychiatry connected with favorable health outcomes and has the potential to inform effective, directed interventions in clinical care. Given POSTER 13 that there is a lack of information regarding resilience research among LGBTQ+ Latino communities, CHA behavioral health sites provide opportunities to investigate and create significant clinical interventions to improve clinical care and treatment outcomes of these patient populations. Inspired by research surrounding strength-based approaches that utilize the conceptual framework of resilience, this quality improvement initiative gathered providers from interdisciplinary professions to draw off their clinical experiences in working with LGBTQ+ Latino patients to design protective interventions for enhanced patient resilience. This intervention focuses on accomplishing the following goals: 1.) To improve clinical recommendations by making them more culturally competent and inclusive; 2.) To develop resource materials for strengthening treatment plans; 3.) To improve the quality of behavioral health care for LGBTQ+ self-identified Latino patient populations, and 4.) To improve patient behavioral health outcomes. Future steps will draw from LGBTQ+ Latino patients for feasibility and acceptability of such an initiative.
Outmigration of CHA Patients We will select a large sample of patients who are Primary Care for ED and Inpatient Care patients of CHA providers and design a questionnaire to ascertain the factors that led them to present to outside hospitals, and interview Author(s): the CHA providers. Shirin Karimi, MD, Medicine
POSTER 14
26 Understanding the Needs of the Background: Latino youth in the United States endure disparities in Latino Population in a Pediatric/ access to quality mental health services. Integrated mental health Behavioral Health Integrated care not only reduces barriers for Latinos but also improves retention, Care Service satisfaction, and outcomes. However, Latino families are rarely engaged in the co-production of integrated care services. Author(s): Aileen Lorenzo, MD, Problem: At Cambridge Pediatrics there is a mental health Psychiatry integrated care service that has a large Latino population. The problem identified at CHA is that there are many no shows for POSTER 15 initial consultation and follow up consultation in this population.
Change/Implementation: Change ideas include identifying the needs of Latino youth and their families to culturally tailor the design of our integrated care service to improve mental health outcomes in this population.
Culture-specific items were adapted from the DSM 5 cultural formulation and included attitudes towards mental health, past help seeking, family involvement in decisions, clinician patient cultural match, and cultural identity.
Results/outcomes: Attitudes towards mental health were generally positive among Latino patients, and few engaged in past non-clinical help seeking. Parents wanted help to prepare for the visit and to be involved in shared decision making. Stigma was connected to shame and feeling pressured into long term treatment.
Implications: Latino families generally reported a positive experience with integrated care, which seemed to be a function of prior treatment experience and receiving care in a familiar pediatrics setting. The link between stigma and a fear of being expected to commit to long term treatment presents opportunities to better prepare Latino families for integrated care.
CEO CLER AWARDEES 27 Promoting Resilience Among Burnout is a well-recognized problem affecting individuals at every Women of Color in the CHA level of training, and residency is a time of particularly high stress Residency Program with a and important transitions. In addition, many women of color face Dinner Seminar Series unique challenges to wellness and maintaining positive mental health while navigating workplace, patient, and social encounters. Burnout Author(s): is associated with many negative outcomes for both providers and Patrice Mann, MD, MPH, patients. This poster will evaluate a four-part seminar series focusing Psychiatry on key, research-supported elements of resilience, tailored to women of color in the CHA residency program. The series consist of four POSTER 16 seminars which combine presentation, activities, and discussion. After each dinner, participants receive a survey where they rate how well they felt the objectives of the dinner were met.
Objectives for the series were: 1) Participants will be able to define resilience and wellness for themselves, and identify factors that promote and challenge their resilience. 2) Participants will become more aware of their own personal narratives and cognitive styles, and understand how these factors influence resilience and wellness. 3) Participants will implement one new coping strategy, and will identify another strategy to try in the future. 4) Participants will endorse increased sense of community with other black women in the residency program. Participants were also asked to provide qualitative feedback on the strengths of the seminar and areas for improvement. We hope that seminar attendees will report high levels of satisfaction with the quality of the meetings, and report that they feel the proposed objectives were met. Feedback will be used to improve the curriculum so that it may be formalized and repeated with other groups of minority women trainees.
28 Social Justice Coalition’s Home Introduction: Many individuals in the CHA community are passionate Series: A forum for learning about advocating for patients’ rights without the afforded resources. about the social determinants Members of the Social Justice Coalition (SJC) designed a monthly of health and organizing around house meeting series to provide a chance for members across health justice advocacy with disciplines to work together, discuss socio-political issues, and create trainees, faculty, and allies in plans of action. the CHA community Objectives: The goal is to provide the space for SJC members to Author(s): engage in a longitudinal conversation about current health justice James B. McKenzie, DO, MBA, issues. We expect that this space will fill a deficit in our medical Psychiatry; Carrie C. Wu, MD, education regarding advocacy, that members will feel a greater sense Psychiatry of fulfillment, and that members will execute initiatives to promote social justice within the CHA community. POSTER 17 Methods: SJC members hosted monthly house meetings with dinner provided. An agenda was created, minutes and attendance were recorded, and plans were set into action.
Results: As a result of successfully held monthly meetings, there has been a forum for SJC members to maintain a consistent dialogue about pertinent health justice issues affecting our patient population. In addition, SJC coordinating members held a Grand Rounds presentation on immigration and created a larger forum for all SJC members to exchange ideas about future initiatives.
Discussion: SJC members have found these meetings to be an invaluable space. Planning consistent meetings dedicated to health advocacy allows for richer discussions, improved morale and more effective initiatives. Continuing the monthly meeting series is a vital part of our clinical education and supports the CHA mission.
CEO CLER AWARDEES 29 Sports Skills and Nutrition Day: Introduction: Childhood obesity is prevalent in our community, Promoting Exercise & Healthy and there are low rates of participation in sports by female youth. Eating in Female Youth Participation in sports has many benefits, including reduction in obesity, decreased rates of depression, decreased risky sexual Author(s): behaviors, improved self-esteem, higher future education levels, Chukwueloka Obionwu, MD, and increased earning potential. Family Medicine residents have Family Medicine; Dominic Wu, held annual Sports Skills Days to address this issue since 2016. MD, Family Medicine; Sarah Bickerstaff, BS, Family Medicine; Objectives: To reduce childhood obesity by engaging female youth, Jessica Knapp, DO, CAQSM, and empowering role models, in exercise and healthy eating. To bring Family Medicine together community stakeholders (Malden Family Medicine, Farmer Dave’s, SNAP, Malden High School, Salemwood Elementary School) POSTER 18 to achieve this goal.
Methods/Materials: Previous Sports Skills Days were evaluated by residents and faculty. For future iterations, we want to improve on attendance and nutrition teaching. High school athletes from the community will volunteer as role models for recruited elementary-age girls. We will recruit through EPIC (i.e. female children ages 6-12 with a BMI >90th percentile at Malden Family Medicine Center), link participants’ families with locally-grown produce while providing education about the CSA process, and involve resident physicians to promote the process of community engagement. We will book two venues to accomodate for inclement weather and send reminder communications to improve show rates.
Results: Key outcome measures include participant’s weight, BMI, participation in sports, and healthy eating habits. Healthy Eating Habits will be assessed using the CDC Youth Risk Behavior Survey. The outcome measures will be collected at two three-month intervals after the event to assess for change.
30 “A Vida Doce” Improving Often patients who are diagnosed with diabetes find that Self-Management Skills of recommended diabetic diets do not include traditional, ethnic Portuguese-Speaking Patients foods. Doctors are used to telling patients to stop eating “junk with Diabetes Mellitus food” and prepare homemade meals, but often are unable to provide details as to how to prepare them. This can lead to confusion and Author(s): poor dietary adherence. Krupa Parikh, MD, Internal Medicine; Sonja Skljaverski, Current supports at CHA for patients with DM includes visits with MD, Internal Medicine; Nicole primary care providers, access to nutrition, pharmacotherapy, and Mushero, MD, Internal Medicine; nurse education services. Limitations noted include: (1) Providers Yamini Saravanan, MD, Internal prescribe healthy eating without concrete recommendations (2) Medicine Limited access & high no-show rate to nutritionists, and (3) Lack of standardized nursing care plans for patients with Limited POSTER 19 English Proficiency.
Our goal is to improve self-management skills of Brazilian Portuguese-speaking patients with DM, through SMAs, by providing hands-on dietary education through cooking demos, and co-creating linguistically tailored self-management tools.
These patients and their families will be empowered and have practical skills about how they can prepare meals to improve their health and control their DM. Short-term outcomes include dietary changes, improved medication adherence, & increased patient engagement. There are pre and post-tests to identify changes in attitudes, knowledge, self-management behavior.
We collect personal narratives from SMA participants with quotes that will be incorporated into nursing care plans. We will co-create a recipe book for culturally appropriate DM friendly recipes that can be shared across clinics.
There is institutional benefit in developing more self-management tools as we move towards the ACO model, which will include 60-65% of patients at CHA.
CEO CLER AWARDEES 31 Providing Point of Care Access to Introduction: According to the 2015 Wellbeing of Malden Report, Community Resource Information programs within the Malden community that address social in a Primary Care Clinic determinants of health are greatly underutilized. Only 45% of eligible Malden residents have received benefits from the supplemental Author(s): nutrition assistance program while 30% of residents spend half of Courtney Scanlon, MD, Family their income on housing alone. These statistics raise questions about Medicine; Jennifer Panosian, access to community resource information. Social and environmental MD, Family Medicine; Tia factors have a significant impact on health outcomes and addressing Tucker, MD, Family Medicine; these issues is important for achieving greater health equity. Racheli Schoenburg, MD, Family Medicine; Emilie Biondokin, MD, Objective: This project aims to increase patient access to community Family Medicine; Elzbieta Jacek, resource information, provide education to patients and assist them MD, Family Medicine; Sarah with participation in local community programs. Bickerstaff, BS, Family Medicine Intervention: We have built an electronic Community Resource POSTER 20 Library that provides user-friendly click-through information for patients seen in clinic. The Community Resource Library will be available on iPads in a designed space within the clinic. Trained volunteers will provide patients with the information they need to start community program enrollment or application processes.
Next Steps: The success of the Community Resource Library will be measured by monitoring the volume of patients utilizing the library space and eliciting patient feedback to assess the value of website content.
Future Discussion: It is hoped that this intervention is proven to be a successful way to improve patient access and increase participation in community resource programs. Providing point of care access to community resource information is the future of primary care and there should be more research dedicated to this area.
32 Impact and Perceptions of Currently, primary care physicians (PCPs) are the leading referral Teledermatology at CHA point for dermatology, as they triage acuity and urgency of patients’ dermatologic concerns. Unfortunately, this conventional model Author(s): creates long appointment wait times due to a mixture of high and low Robert Stavert, MD, Dermatology; quality referrals. In addition, access to dermatologists is unequally Tedi Begaj, MD, Internal Medicine; distributed, even though underserved urban patients have higher Allison Dobry, MD, Internal rates of chronic dermatologic disease. In 2013, Cambridge Health Medicine; Rebecca Droms, MD, Alliance (CHA) implemented the Teledermatology Service, which Internal Medicine; Sumi Sinha, allows PCPs to place virtual dermatologic consults by uploading MD, Internal Medicine photos to EPIC, and in return receive diagnostic and triage support from dermatologists. We reviewed data from over 3,000 consults POSTER 21 placed since the program’s inception to evaluate its impact on CHA patients and providers. Preliminary data from 734 patients shows an average age of 44.2±17.4 years with a predominance of female patients (63.2% vs 36.8%). Photos were adequate for diagnosis in 86.2% of encounters. Teledermatology consultation results in recommendation of topical, systemic or both treatments in 44.1%, 4.5% and 9.9% of encounters, respectively. In addition, 36.6% of teledermatology encounters recommended dermatologic follow- up, of which 92.2% were scheduled, and 78.9% were attended by patients. Of the 21.1% of missed visits, 71.2% were due to no-shows while 28.8% due to cancellations. Thus far, the teledermatology service has increased access to high-quality dermatologic care. Preliminary data shows that virtual patient triage provides PCPs with recommendations for appropriate treatment options and limits low acuity dermatology appointments. Further investigation can elucidate the true cost effectiveness and health benefits of teledermatology implementation at CHA.
CEO CLER AWARDEES 33 Antimicrobial Susceptibility Background: National studies have shown that antimicrobial Among Uropathogens Causing resistance among uropathogens have increased over time, in Acute Uncomplicated Cystitis particular, among Escherichia coli. With resistance patterns varying at Cambridge Health Alliance geographically and by community, it is imperative to evaluate for local antimicrobial susceptibility. At Cambridge Health Alliance Author(s): (CHA), empiric treatment of acute uncomplicated cystitis (AUC) Frances Ue, MD, MPH, Internal varies by provider and site. There is a need for a systematic evaluation Medicine; Rebecca Osgood, MD, of antimicrobial susceptibility among uropathogens to provide Pathology; Lou Ann optimal antibiotic treatment. Bruno-Murtha, DO, Infectious Diseases Objectives:
POSTER 22 1. Determine the prevalence of antimicrobial resistance among uropathogens causing AUC in the primary care setting at CHA,
2. Characterize risk factors that may predispose patients to resistance, and
3. Develop optimal management practices for AUC based on the antimicrobial resistance data obtained.
Methods: 200 clean catch urine specimens from adult female patients who met criteria for AUC were collected prior to antibiotic initiation from the Primary Care Center at Cambridge Hospital and Malden Family Medicine. These urine cultures were evaluated for antimicrobial susceptibility via standard laboratory protocol. Minimal inhibitory concentrations (MIC) were reported for each antimicrobial tested.
Results: Data collection and analysis in process.
Implications/Lessons Learned: Our results will inform best practices for treatment of AUC, including the development of an updated AUC treatment algorithm for our specific, local catchment population at CHA. In collaboration with nurses and physicians, these findings will be disseminated to the ambulatory settings.
34 COMMUNITY HEALTH AND HEALTH POLICY
A State-Level Report Card on Introduction: The Affordable Care Act (ACA) reduced the number of the Impact of the Affordable uninsured adults by nearly 40%. State governments had substantial Care Act on Insurance Coverage discretion in implementing the reform but little is known about how for Racial and Ethnic Minorities coverage gains varied across the United States states for black, and Low-Income Americans Hispanic and lower-income Americans.
Author(s): Objective: To quantify state-level improvements in coverage after Lynn Anderson, MD, Medicine; the ACA for black, Hispanic and low income Americans. Erica C. Dwyer, MD, PhD, Medicine; Megan LaPorte, MD, Methods: We analyzed data from the Behavioral Risk Factor Medicine; Deborah Lee, MD, Surveillance System (BRFSS), representative statewide cross- Medicine; Gregory Lines, MD, sectional surveys in the pre-ACA period (2012 - 2013) and the MPH, Medicine; Kira Mengistu, post-ACA period (2015 - 2016). For black (non-Hispanic), Hispanic MD, Medicine; Daniel Novinson, and low-income (<$35,000/year) adults (age 18-64), we estimated MD, MPH, Medicine; Sonja pre- to post- ACA changes in insurance coverage for each state Skljarevski, MD, Medicine; Gaurab using logistic regression models. Basu, MD, MPH, Medicine; Danny McCormick, MD, MPH, Medicine; Results: The uninsurance rate declined for black people in 39 states Hugo Torres, MD, MPH, Medicine with the largest decline (relative) in Kentucky (72.2% [44.1 to 110.6]; absolute reduction, 39.2% [4.4 to 74.1]). In North Dakota, there was an POSTER 23 increase in the uninsured rate (29.9% [-62.7 to 91.0]; absolute increase of 6.6% [-23.8 to 10.6]). Among Hispanic and lower-income Americans, similar patterns of variation were observed. The proportion remaining uninsured three years after ACA implementation varied widely across states: For black people the range was 7.3% (DC) to 25.3% (Nebraska); for Hispanic people the range was 8.1% (Hawaii) to 61.8% (North Carolina).
Conclusions: Post-ACA improvement of insurance coverage for black, Hispanic and lower-income Americans varied greatly among U.S. states. Our findings raise concerns about proposed legislation that would provide states with greater discretion in implementing federal health programs.
COMMUNITY HEALTH AND HEALTH POLICY 35 Assessing the Impact of a Background: Worksite wellness programs are designed to support Worksite Wellness Initiative employees in developing and maintaining healthy habits, and have on Employee Engagement historically been developed with return-on-investment (e.g. reduced employee health care costs) as the primary motivation. However, Author(s): there has been a recent change in motivation towards value-on- Carolyn Ballard, MS, RD, Human investment which encompasses a range of benefits including Resources; Sharon Touw, MPH, employee engagement. Recognizing this trend, the Cambridge Institute for Community Health; Health Alliance (CHA) Wellness Initiative has incorporated strategies Elaine Zhang, BS, Institute for to increase both its reach and employees’ engagement levels. Community Health Methods: Reach and effectiveness of Initiative activities, such as POSTER 24 the Walking Challenge, were evaluated using surveys. Additionally, a survey was conducted with Wellness Ambassadors, employees who volunteer to represent the Initiative within their departments.
Results: In 2017, the Walking Challenge, the Initiative’s most popular activity, included 957 participants, a 349% increase since the initial Challenge in 2013. 46% were first-time participants. 66% of participants reported that the Challenge contributed to building stronger department relationships, and 68% felt more connected to the wider CHA community. Additionally, 91% of Wellness Ambassadors reported that this role has helped them to improve the work culture of their department, and 100% felt that they were able to make a positive difference in their co-workers’ health.
Conclusion: The Wellness Initiative is effectively engaging employees in its programs and has documented its contribution to CHA’s goal of having an engaged workforce.
36 The Impact of the Affordable Cardiovascular disease (CVD) is the leading cause of morbidity Care Act on Coverage and and mortality in the United States. While CVD and cardiovascular Access on Americans with risk factors (CVRF) are more prevalent among racial minorities and Cardiovascular Disease or low-income Americans, these groups are more likely to lack health Multiple Cardiovascular insurance coverage and access to care. We assessed: 1) whether the Risk Factors ACA was associated with improvements in insurance coverage and access to care; 2) whether the ACA’s optional Medicaid expansion Author(s): resulted in better coverage and access; and 3) whether racial/ethnic Ameen Barghi, MPP, (CIC disparities in outcomes improved. Student), Harvard Medical School; Hugo Torres, MD, MPH, We analyzed nationally representative data from the Behavioral Medicine; Nancy R. Kressin, PhD, Risk Factor Surveillance Survey (BRFSS) in the two years (2012- BU School of Medicine; Danny 2013) prior to ACA’s implementation and two years of the post- McCormick, MD, MPH, Medicine implementation period (2015-2016). We compared changes in health insurance coverage as well as access to care using three measures: POSTER 25 1) not foregoing a doctor visit due to cost in the last year (affording physician visits); 2) having a personal doctor; and 3) having a check-up in the past year.
We found pre- to post-ACA increases in the proportion of all Americans with CVD/CDRF in all health outcomes measures. Finally, many continue to lack coverage: 17.5% overall, 33.2% of those with lower incomes, 12.9% of black and 28.7% of Hispanic people.
The ACA was associated with a moderate improvement in insurance coverage and small improvements in access to care overall and larger improvements among lower-income, black, Hispanic Americans and those residing in Medicaid expansion states. High proportions of Americans with CVD and CVRF continue to face access barriers and lack insurance coverage.
COMMUNITY HEALTH AND HEALTH POLICY 37 The Power of Collaboration: Introduction: Malden, Massachusetts is an ethnically and economically Strengthening the CHA diverse community with a large underserved population. As CHA partnership with Malden Public Malden Family Medicine Center strives to meet the needs of the Schools Title I program for community, one essential alliance is with Malden Public Schools’ community benefit Title I program. Title I is a federally funded program that is part of “No Child Left Behind,” designed to support students and families Author(s): affected by poverty. Malden Public Schools’ (MPS) Title I program is Devorah Donnell, MD, Family actively engaged with students’ parents, with enriched programming Medicine; Renée Cammarata including parent literacy and math education (“Parent Academy”), Hamilton, MSW, MPA, CHA Health to enhance student success. Yet there remain many unmet student Improvement; Paul McCarthy, and family needs, which MPS Title I program hopes can be alleviated Malden Public Schools Title 1 through increased collaboration with CHA and Family Medicine Parent Coordinator Residents.
POSTER 26 Objectives: By continuing CHA Family Medicine involvement in MPS Title I’s Parent Academy presentations, we aim to aid this historically marginalized community while strengthening the CHA and MPS Title I relationship for ongoing collaboration.
Methods: I presented at the January 2017 and January 2018 Title I Parent Academy sessions, teaching requested topics—nutrition for the whole family, and understanding child development for appropriate limit setting and bullying intervention. CHA’s annual involvement for this health topic Parent Academy led to further discussion with MPS Title I leaders to better understand the community’s needs and social determinants of health.
Results: For the January 2018 CHA/Title I collaborative Parent Academy, there were 26 parents in attendance, with primary languages including Arabic, Brazilian Portuguese, Haitian Creole, Chinese, Spanish, and English. When asked via survey, the event was rated as a positive experience by 26 out of 26 parents. Parents requested that there be more of these health-oriented presentations.
Discussion/Recommendations: CHA involvement with the MPS Title I project has great potential for ongoing community benefit. Parents found the CHA presentations at the Parent Academy helpful, which will continue annually. Though extensive discussion with MPS Title I leaders, we identified two additional needs of the Malden Title I students and families—multilingual parent services and resource awareness. The MPS Title I program presently is without interpreter services for parents, limiting non-English speaking families’ benefit from these programs. Students and families struggling with poverty have great needs, with reports of students not coming to school because they did not have winter coats or boots. There are many community resources from which these families would benefit, but they need help finding them. The future of this project will include partnering with existing community resources and coalitions, such as Malden’s Promise, to bring resources from the hospital network to benefit the public school’s underserved families. This project deepened the CHA and MPS Title I program partnership, with great potential for continued community benefit.
38 2015-2017 CHA Cancer Introduction: Every three years, the CHA Cancer Committee conducts Community Needs Assessment: a Community Needs Assessment (CNA) to study cancer trends in our Comparing Demographics of service population. We focused the current analysis on Ambulatory CHA Panel Patients who are Quality Goal (AQG) patients tracked by the CHA PCP dashboard for Screened vs Not Screened breast, colorectal, and cervical cancer. Our objective was to identify for Colorectal, Cervical, and specific patient populations that might be less likely to be screened Breast Cancer for these cancers.
Author(s): Methods: We examined association of cancer screening and Taisha Joseph; Sarah Primeau, patient characteristics on patients from the CHA AQG dashboard MSW, MPH, Community Health (7/1/2015–6/30/2017). Using multivariate logistic regression, we Improvement; Rumel Mahmood, estimated the odds of being screened for breast, colorectal, and Quality and Patient Safety; cervical cancer, adjusting for demographics, socioeconomics, and Karen Finnegan, Institute for pertinent medical history. Community Health; Heidi Rayala, MD, PhD, Surgery Results: Screening rates for breast, cervical, and colorectal cancer, were 72%, 81%, and 71%, respectively. Patients with a documented POSTER 27 history of substance abuse (56%, 74%, and 65% respectively) or smoking (68%, 80%, 70% respectively) were less likely to be screened (p<0.001 for all). Patients with a PCP at Malden and Revere (p<0.001 for both) as well as people with public insurance/Medicaid were also less likely to be screened (p<0.001). Ethnic minority groups were more likely to be screened than our White/European patients; with the exception of North African/Middle Eastern, with rates of 65% (p<0.01), 78% (p<0.0001), and 66% (p<0.001) for breast, cervical and colorectal, respectively.
Discussion: This study identifies at-risk CHA patient populations that we can target for future cancer screening outreach.
COMMUNITY HEALTH AND HEALTH POLICY 39 Changes in Psychiatric Introduction: The week of the 2013 Boston Marathon brought a Emergency Room series of unique traumatic events to the greater Boston area. Visits Following the Boston Bombing Objectives: This study examines the characteristics of patients seen by Psychiatric Emergency Services (PES) at a Boston-area community Author(s): hospital following the 2013 Boston Marathon bombings. Gaddy Noy, DO, Psychiatry; Amber Frank, MD, Psychiatry Methods: Demographics, prior diagnoses, trauma history, and presenting problems of patients evaluated by the Cambridge Hospital POSTER 28 PES in the two months following the bombings were compared to those seen in the two months preceding the bombing. A subset of cases in which the bombing was explicitly mentioned was also examined in greater detail.
Results: Post-bombing PES visits demonstrated a broad range of demographics, prior diagnoses and presenting problems. Only 36 evaluations (8.2%) out of 440 directly mentioned the bombings, of which only 13 presented with symptoms of PTSD or acute stress disorder (n= 13, 36.1%). New-onset PTSD symptoms directly related to the bombing were rare (n= 4 evaluations), 11.1% of the 36.
Discussion: PES patients seen after a local terrorist event are likely to have a broad range of presenting problems and prior diagnoses. While presenting problems can include symptoms of PTSD or acute stress disorder related to the traumatic event, this may be a minority of the total population seen. While a PES plays a critical role in aiding those with mental health crises, it may not be the primary site where new cases of PTSD or Acute Stress Disorder are likely to be seen in the immediate aftermath of a terrorist attack.
See, Test and Treat: A Program See, Test & Treat is a College of American Pathologist Foundation That Fulfills the Cambridge initiative that delivers free, pathologist-led cervical and breast Health Alliance Mission cancer screening, same day results, and education to vulnerable women in US communities. The goal of See, Test & Treat is to Author(s): engage underserved patients in community health care services Rebecca Osgood, MD; Kate by offering same-day screening results and access to follow-up Harney, MD; Sarah Primeau, care in a culturally appropriate setting. MSW, MPH, Community Health Improvement; Megan Meany, In a single-day, culturally appropriate program, women receive CHA Foundation; Bonnie a pelvic and breast exam, a Pap test with same–day results, a Martin, Marketing; Alexis Ladd, mammogram with same-day or prompt results, connection to Marketing; Mary Cassesso, follow-up care plans, interpretive services, translated educational CHA Foundation sessions and materials, and a healthy meal. In partnership with the CHA Foundation, CHA offered the first program after identifying a POSTER 29 target population and registered 60 patients for visits for PAP and mammograms on March 3, 2018. Volunteer Health Advisors recruited the churches, schools and other places of gathering to recruit patients in need of these preventable cancers. In 2016, See, Test & Treat programs’ abnormal Pap results ranged from 10% to 20%, and abnormal mammogram results ranged from 6% to 23%, far above national averages. The poster will detail our findings and the outcome of the CHA event. 40 ACE Assessment in Introduction: The research on long-term physical and mental health Clinical Practice: A Pediatric effects of adverse childhood experiences (ACEs) demonstrates the Integrated Care Model need to screen for, prevent, and intercept child trauma exposure. However, best practices regarding ACE assessment in pediatric clinical Author(s): contexts, including integrated models of care, have not been studied. Priya Pathak, BSc, MD Candidate; Katherine E. Grimes, MD, MPH, Objectives: Our objective is to identify challenges and opportunities Psychiatry of screening for ACEs within primary care to inform clinical practice in an integrated care model. POSTER 30 Methods: This is a qualitative pilot study nested within a SAMHSA- funded integrated care initiative “Enhancing Systems of Care” (ESOC). Baseline assessment by the E-SOC team includes ACE screening using the CYW Adverse Childhood Experiences Questionnaire (ACE-Q). Unlike research applications that rely only on cumulative ACE score, our assessment addresses each individual ACE item. Responses to ACE items are used to guide therapeutic dialogue and clinical follow-up. In-depth interviews and focus groups were conducted with clinicians to explore provider perspectives on the value and feasibility of integrating ACE assessment into the clinical environment.
Results: Preliminary data suggests that ACE assessment is acceptable to families, does not burden providers, and helps to foster therapeutic dialogue and inform care recommendations.
Discussion/Recommendations: Our findings support an emerging evidence-based approach within prior literature suggesting that screening for ACEs can be therapeutic in fostering dialogue and providing supportive acknowledgement for families. Further research is needed to assess the longitudinal impact of ACE-guided clinical service delivery on outcomes, such as patient functioning, services utilization, and expense.
COMMUNITY HEALTH AND HEALTH POLICY 41 Differences in Rates of Suicidal Introduction: Gender minority individuals (transgender or nonbinary) Ideation and Potential Suicide have higher rates of mental health disorders than the general Attempt Among Disabled and population. Around 40% of gender minority persons have reported Gender Minority Medicare attempted suicide and is more frequent in youth, with mental illness Beneficiaries from 2009-2014 and with no support.
Author(s): Objectives/hypothesis: We studied rates of suicide ideation and Ana Progovac, PhD, Health Equity potential suicide attempt in Medicare claims between 2009-2014, Research Lab; Brian Mullin, expecting to confirm the high rates. Health Equity Research Lab; Maria Jose Sanchez, MD, Health Methods: We identified gender minority beneficiaries using a Equity Research Lab; diagnosis-code algorithm developed by the Centers for Medicare Alex McDowell, MPH, MSN, and Medicaid Services, and compared them to a 5% random sample Harvard University; Sari Reisner, of beneficiaries from 2009-2014 within disabled or age ≥65 cohorts. ScD, Harvard Medical School; The presence of diagnosis codes on claims related to suicidal ideation Emilia Dunham, MBA, MPP; and attempt were observed. Logistic regression models were used for Cynthia Telingator, MD; binary outcome variables (any attempt or ideation), adjusting for age Benjamin Le Cook, PhD, MPH, only and age and mental health conditions. Health Equity Research Lab Results: Adjusting for age only, disabled gender minority beneficiaries POSTER 31 had higher rates of potential suicide attempt/ideation (9.2%) compared to non-gender minority disabled beneficiaries (2.5%). Predicted means fell to 2.7% vs. 1.4% respectively after adjusting for mental health conditions (both p<0.0001). Aged gender minority beneficiaries had higher rates of potential suicide (2.5%) than non- gender minority aged beneficiaries (0.9%) after adjusting for age only, and the difference was not attenuated after adjusting for mental health conditions (1.5% vs. 0.8%, respectively, both p<0.0001).
Recommendations: These claims-based findings add to existing literature showing higher rates of suicidality for gender minorities and calls-out for immediate suicide prevention promotion.
42 Inpatient Medicaid Cost and Introduction: Food insecurity worsens health and increases healthcare Utilization Patterns After utilization and costs. The Supplemental Nutrition Assistance Program Changes in Supplemental (SNAP) reduces food insecurity among recipients but does not Nutrition Assistance Program eliminate it. Benefit Levels Objectives and Hypothesis: Changes in SNAP benefits may affect Author(s): healthcare utilization and costs via effects on food insecurity. SNAP Rajan Sonik, PhD, JD, MPH, allotments increased in April 2009 under the American Recovery and Psychiatry Reinvestment Act (ARRA) and decreased in November 2013, yielding an opportunity to test this hypothesis. I examined trends in inpatient POSTER 32 Medicaid costs and utilization in response to the 2009 and 2013 changes. I compared responses to those among Medicare recipients and among those with varying likelihoods of having a disability.
Methods: Interrupted time series models estimated and compared inpatient utilization and cost responses to the 2009 and 2013 SNAP changes. Analyses used 2006-2014 Healthcare Cost and Utilization Project National (Nationwide) Inpatient Sample data. Models adjusted for inflation, enrollment and other covariates.
Results: After the 2009 SNAP increase, Medicaid cost growth fell nationally from +0.85 to +0.36 percentage points per month (–0.49, 95% CI: –0.73, –0.25). After the 2013 SNAP decrease, cost growth rose to +2.09 percentage points per month (+1.73, 95% CI: +0.37, +3.09). Monthly admissions followed similar patterns. Effects were elevated among people with a high disability likelihood and for Medicaid as compared to Medicare recipients.
Discussion: Changes in SNAP benefit levels were associated with changes in inpatient Medicaid cost and utilization patterns. Increasing food aid may reduce inpatient Medicaid costs.
COMMUNITY HEALTH AND HEALTH POLICY 43 A Tale of Three Projects: Introduction: Health system transformation (HST) efforts are Co-Production as an Approach being undertaken across the healthcare industry in different to Health Systems Transformation modalities and involving stakeholders at all levels. In this context, co-production as an approach to HST is gaining traction, but its Author(s): impact remains unclear. Martina Todaro, MPA, Institute for Community Health; Maren Methods: We compared and contrasted the evaluations of three Batalden, MD, MPH, Performance initiatives that adopted co-productive methods to promote HST to Improvement; Ann Hwang, MD, see the effect of these approaches on the project participants. The Community Catalyst; Carolyn initiatives were: from clinicians’ perspective (CHA-Gold Innovation Fisher, PhD, Institute for Fellowship (Gold)); and from healthcare consumers’ perspectives Community Health (Family Voices (FV), and Community Catalyst’s Consumer Voices in Innovation grant program (CVI)). POSTER 33 For CVI and FV, we assessed impact on participants by administering surveys at multiple timepoints, conducted qualitative interviews and analyzed secondary data. For Gold, we conducted four cycles of qualitative interviews and analyzed secondary data.
Results: Across the three initiatives, participants reported increased involvement in HST. 43% of FV participants reported that they are involved in improving healthcare systems and services. 56% of CVI consumers have increased their involvement in HST advocacy in the last year. All Gold fellows (N=11) are promoting institutional change through their projects.
Discussion: Co-productive methods, rather than top-down approaches, are widely appreciated by participants in these initiatives. Gold clinicians report change projects require the engagement of more people than expected and appreciate guidance provided around this. CVI and FV consumers report feeling empowered by the opportunities to participate in decision-making groups. Coproduction is a fruitful approach to the HST process, and further study may reveal its impact on outcomes.
44 Acknowledging the Role of Background: Engaging fathers in raising their young children is Fathers: The experience of associated with numerous benefits for children including decreased a local parenting program behavioral problems in adolescence and young adulthood, better than average social functioning as children and adults, better health Author(s): outcomes and improved economic status. Since 2010, Baby U, a Sharon Touw, MPH, Institute Cambridge-based parenting program, has provided education and for Community Health; Shawn support to predominantly low-income parents of young children. Proctor, BS, City of Cambridge In 2013, they intensified efforts to engage fathers by updating Center for Families; Abigail recruitment strategies and modifying program and staffing structures. Tapper, MPH, Institute for Community Health Methods: Baby U used surveys and interviews to understand parents’ experience, as well as their knowledge of child development and POSTER 34 parenting strategies and their engagement in behaviors that foster children’s social, emotional, and cognitive development. Paired t-tests were used to determine changes from before to after program participation within gender sub-groups. Interviews were analyzed for common themes.
Results: Fathers appreciated the acknowledgement of their role as an equal parent and emphasized the value of having a safe space to discuss parenting challenges and the relationships developed with other fathers. In a cohort of 47 fathers, there were significant gains in knowledge of the importance of talking and playing with young children (p<.0001) and knowledge and use of different tools and strategies for parenting (p<.0001 for knowledge and use) from before to after program involvement. Fathers reported dedicating more quality time for their children and incorporating positive discipline strategies.
Conclusions: Baby U is successfully engaging fathers in raising their young children. Further evaluation is needed to determine the impact on Baby U children.
COMMUNITY HEALTH AND HEALTH POLICY 45 Evaluation of CHA’s Complex Introduction: CHA’s Complex Care Management (CCM) program Care Management Program engages high-risk patients to improve health outcomes, reduce avoidable medical expenses, and strengthen primary care team Author(s): interventions. We evaluate the impact of CCM and explore Greg Watt, MSW, Primary Care stakeholder perceptions of the program. Complex Care Management; Sharon Touw, MPH, Institute for Methods: We examined CHA utilization during baseline (12 months Community Health; Nicholas before CCM enrollment) and follow-up (12 months after CCM Cone, Primary Care Complex Care enrollment) for 1,090 patients enrolled in CCM between 2014 and Management; Karen Finnegan, 2016. We interviewed 15 patients and six Care Managers participated MPH, Institute for Community in a focus group to provide program context. Health; Kristin King, MPPM, Institute for Community Health; Results: Patients with acute care utilization (one inpatient stay and/ Leah Zallman, MD, MPH, Institute or two or more Emergency Department visits in a 12-month period) for Community Health; Eleni Carr, decreased by 9% after CCM enrollment (pre-CCM: 57%, post-CCM: MBA, LICSW, Accountable Care 48%, p<0.001). Mean ED visits decreased from 3.0 to 1.9 per year; Organization mean inpatient stays decreased from 0.9 to 0.7 per person per year. Patients felt that they were better able to manage their health and POSTER 35 appreciated their Care Managers’ support and assistance with care coordination. Care Managers defined success as establishing trusting relationships with patients, improving patients’ experience of care and alleviating the workload for primary care teams.
Discussion: Additional research is needed to understand acute care utilization outside of CHA and to confirm findings in a matched comparison study. The CCM program is identifying rising risk patients for whom CCM could avert avoidable medical expenses. Care Managers and interviewed patients defined success in terms beyond utilization patterns.
46 Reducing Childhood Obesity: Introduction: In 2015, approximately 28-45% of Malden High Promoting Exercise and School students were overweight or obese with <50% performing Healthy Eating recommended pediatric exercise goals. Female sports participation lags behind males. Sports participation offers numerous benefits Author(s): including reductions in obesity. Dominic Wu, MD, Family Medicine; Chukwueloka Obionwu, Objectives: This project aimed to increase childhood female sports MD, Family Medicine; Sarah participation, reinforce healthy nutrition habits, and introduce families Bickerstaff, BS, Family Medicine; to community-supported nutrition resources. Jessica Knapp, DO, CAQSM, Family Medicine Methods/Materials: A chart review identified female patients at CHA Malden between 6-12 years old with a BMI >90th percentile who were POSTER 36 recruited to attend the expanded second annual “Sports Skills Day.” The participants were taught various sports skills by female high school athlete role models while physicians taught healthy eating and social workers signed families up for SNAP. Participants and parents completed de-identified pre- and post-intervention qualitative and quantitative surveys.
Results: 23 participants aged 6-12 years old participated. A majority of participants reported eating sugary treats multiple times a week. 69.6% ate vegetables less than once a day. 100% of participants would recommend the event to their family or friends. 69.6% reported they would be “very likely” to increase their vegetable intake after the intervention. All participants indicated they felt more confident about participating in sports.
Discussion/Recommendations: Early exposure to sports and healthy eating habits may increase future sports participation and reinforce improved nutrition in youth populations. Due to inclement weather, however, only 23/100 participants were present. Our goal is to increase the number of participants and improve the nutrition teaching portion for the next annual event.
COMMUNITY HEALTH AND HEALTH POLICY 47 Immigrants Contributed $27.9B Background: Immigrants in the United States utilize less care than More to Private Insurers Than U.S.-born individuals, and contribute more to Medicare than the They Took Out in 2014 value of Medicare-funded services that they receive. With high workforce participation rates, many are privately insured. We aimed Author(s): to understand the contributions by and on behalf of immigrants and Leah Zallman, MD, MPH, Institute U.S.-born individuals to private insurance and insurers’ expenditures for Community Health, Steffie for their care. Woolhandler, MD, MPH, City University at Hunter College, Methods: We analyzed data from the Medical Expenditure Panel Sharon Touw, MPH, Institute Survey to determine private health insurance expenditures and for Community Health, David individual premiums. We extracted employer contributions to Himmelstein, MD, City University private insurance premiums from the Annual Social and Economic at Hunter College, Karen Supplement to the Current Population Survey. We tabulated Finnegan, MPH, Institute for private health insurance contributions and insurers’ expenditure Community Health for immigrants and U.S.-born individuals.
POSTER 37 Results: In 2014, immigrants accounted for 12.0% of private insurance contributions, or $81.2 billion, but only 7.9% of private insurer’s expenditures, or $53.3 billion. This resulted in a net contribution of $27.8 billion, or $1,226 per immigrant. In contrast, U.S.-born individuals contributed $597.5 billion to private insurance and accounted for $625.3 billion in expenditures, an average net deficit of -$174 per person (p <0.0001 for comparison with immigrants). Between 2008 and 2014, immigrants generated a surplus ranging from $20.3B to $31.6B, resulting in a cumulative surplus of $192.5B.
Conclusions: Immigrants cross-subsidize the care of privately insured native-born persons, mirroring immigrants’ previously documented subsidy to the Medicare Trust Fund. Our findings quantify the contribution of immigrants to the solvency of the U.S. healthcare market and contradict the widespread assumption that immigrants are a drain on health care resources.
48 HEALTH PROFESSIONS EDUCATION
Teaching Medicine Interns Introduction: A set of 26 SGIM-endorsed “minimum geriatric Minimum Geriatrics competencies for IM-FM residents” (MGC) was published in 2010. Competencies within Providing residents geriatrics training can be challenging in programs a “4 + 2” Schedule with an “X + Y” (“inpatient + ambulatory”) schedule due to faculty availability and spacing of sessions across time. Author(s): Serena Chao, MD, MSc, Geriatrics Objectives: We describe our experience in teaching MGC within the Division; Anne Brouha, MD, longitudinal geriatrics curriculum embedded in CHA medicine interns’ Geriatrics Division; Rachel Stark, “4 + 2” schedule. MD, Medicine Methods: During the two-week ambulatory block, interns spend POSTER 38 one day in a geriatrics ambulatory site (house calls, PACE, nursing home). Geriatrics division faculty give core lectures during these clinical sessions. For AY16-17, we revamped lectures to address MGC related to medication management, cognitive health, complex chronic illnesses, palliative care and ambulatory care. Interns voluntarily completed anonymous self-assessment surveys pre- (7/16) and post-rotation (6/17), rating their level of confidence on MGC addressed by the curriculum using a five-point Likert scale.
Results: On pre- and post-surveys, interns (total=eight) reported improvement in confidence ratings on all items, with the greatest average point gains seen in practice of optimal geriatric pharmacotherapy (2), initiation of treatment for dementia patients (1.37), capacity determination (1.5), individualization of screening recommendations (1.63), and identification of older patients eligible for certified home health agency (CHHA; 2.13) and non-CHHA community services (1.5).
Discussion: We developed a longitudinal geriatrics curriculum within the context of our “4+2” immersion schedule which is easily reproducible by other programs. Aligning curricular content with the MGC has resulted in interns’ improved confidence in several important geriatrics skills.
HEALTH PROFESSIONS EDUCATION 49 Diagnosing the Learner: Needs and objectives: Clinical reasoning is an important yet complex An analysis of how our learners process that has been increasingly recognized for its importance over are clinically reasoning the past few decades. However, the exact characteristics that define it remain subject to debate. It is integrated into medical school curricular Author(s): competencies and accreditation bodies’ standards. As educators we Rachel Hathaway, MD, Medicine; are challenged to help learners develop expertise in this topic that Michael McShane, MD, MEd, has many expert recommendations of how to teach it, but without Medicine; Hugo Torres, MD, MPH, evidence based assessment tools. Therefore we set out to describe Medicine; David Scales, MD, how clinical reasoning changes across the educational continuum from PhD, Medicine; Priyank Jain, MD, undergraduate medical education to graduate medical education to Medicine; Joshua Onyango, MS, expert. Our focus is on how problem representation, a specific skill in Harvard Graduate School clinical reasoning, is developed. This is a critical skill for physicians as it of Education; David Cameron, quickly conveys how one is interpreting a case and is vital for efficient BU School of Public Health; and accurate communication. Richard Pels, MD, Medicine Setting and participants: We collected one-liners (a.k.a. problem POSTER 39 representation statements) from our learners after reviewing real cases. Our learners range from 20 Harvard Medical School students in their clinical year to 15 PGY1-3 Internal Medicine residents at Cambridge Health Alliance. We also included faculty one-liners for comparison.
Description: We aim to describe how problem representation changes across the educational continuum from undergraduate medical education to graduate medical education to expert. We are performing a mixed methods analysis of one-liners (problem representation statements) to describe factors that influence quality and sophistication.
Evaluation: We are using a grading rubric that accounts for complexity of the case and accuracy of the components of problem representation. We have several evaluators, ranging from senior to junior Internal Medicine faculty and a medical student, in order to ensure inter-observer reliability. Through our analysis of this data, we hope to identify concrete factors critical for the accurate assessment of one-liners.
Discussion: Through teaching clinical reasoning to learners at various stages, we have identified that problem representation is an important yet challenging skill to develop. However, we have limited ability to assess our learners’ clinical reasoning. By focusing on a core skill, problem representation, we hope to identify key factors that make up a one-liner as well as discrete stages of problem representation development. We expect learners with more medical education will score consistently higher. We hope that by better understanding how learners progress in developing the skill of problem representation, we will be able to develop a useful formative and summative assessment tool. Furthermore, such a tool would be useful for educators as it would map milestone achievement in the development of clinical reasoning competence. In addition to being useful for diagnosing learners’ developmental progress, it would help educators to better target educational interventions.
Impact: By focusing on a core skill, problem representation, we hope to identify key factors that make up a one-liner as well as discrete stages of problem representation development. This will contribute to the currently limited literature about problem representation and its assessment. 50 Innovation in a Safety-Net Introduction: We stand on the verge of a revolution in bedside Hospital: Building a point-of-care clinical care. The evidence supporting point-of-care ultrasonography ultrasound curriculum through a (POCUS) shows improved patient outcomes and satisfaction, faster resident-led, low-resource model and more accurate diagnoses, and fewer complications. Newer technology is making ultrasounds cheaper and more portable. There Author(s): is high interest among internists to adopt this technology but lack of Kay Negishi, MD, Internal relevant and easily available training is a big barrier. Medicine; John DeAngelis, MD, RDMS, Emergency Medicine; Objectives: The goal of our project is to address this barrier by Jonathan Opraseuth, MD, building a POCUS curriculum for internal medicine (IM) faculty Radiology; Priyank Jain, MD, and residents at CHA, a safety-net hospital with limited financial, Internal Medicine infrastructural, and human resources.
POSTER 40 Methods: With a “training the trainer” model, we identified four motivated hospitalists and residents to receive training from a radiology and an emergency medicine attending Physician. The curriculum combines formal teaching sessions, image review sessions, and learner-driven scanning sessions. Pre- and post-intervention surveys will be conducted. The four new trainers are expected to train other IM learners in the future.
Results: While this project is ongoing, several key components to building a curriculum have become evident: Buy-in from traditional funding sources is difficult, necessitating grants and donations to serve as “seed money.” Cross-departmental collaboration plays a critical component, especially without pre-existing expertise within IM. Tapping into resources outside of the institution is important.
Discussion: It is possible to establish a POCUS curriculum in a low-resource community hospital setting. Resources for internist- focused POCUS training programs are still sparse. We envision sharing our curriculum and educational infrastructure to other IM programs across the country.
HEALTH PROFESSIONS EDUCATION 51 Generating Best Precepting Introduction: Physician educators often rely on personal experiences Practices through a Collaborative, to develop their teaching styles, with minimal formal education about Multi-Disciplinary Faculty learning theories and best practices of teaching. Additionally, most Development Workshop training programs do not offer physician educators regular, continual training opportunities to improve their clinical teaching skills. Author(s): Tara Singh, MD, OBGYN; Bianca The Harvard Medical School (HMS) Cambridge Integrated Clerkship Shagrin, MD, Pediatrics; Yamini (CIC), is a transformative longitudinal integrated clerkship (LIC) at Saravanan, MD, Internal Medicine Cambridge Health Alliance (CHA). Over the past 15 years, there have been limited faculty development sessions. POSTER 41 Objectives and/or Hypothesis: We created a faculty development workshop to establish a community of educators in the CIC at CHA, to honor and renew enthusiasm in preceptors, and provide opportunities for knowledge and skill improvement in clinical teaching.
Methods/Materials: We conducted an educational needs assessment of the CIC students and a faculty needs assessment survey. This data was used to design the inaugural, multi-disciplinary, faculty development workshop. Faculty from different disciplines convened for one of two evening sessions to discuss and develop best practices for teaching in a longitudinal clerkship.
Results: Thirty-four of 70 faculty attended the workshop. Faculty participated in small and large group discussions, sharing best practices of clinical teaching for longitudinal preceptors. A summary of practices was emailed to all faculty attendees to edit. The organizers collated this collaborative work of best precepting practices for the CIC.
Discussion/Recommendations: Collaborative faculty development programs from multi-disciplinary faculty in LICs can lead to rich discussion and development of best practices which may be used to inform teaching and faculty development across institutions.
52 Developing a “Wellness Background: Stress and the resulting risk of burnout is a concern Space” to Enhance Our in residency training. Our wellness space initiative originated from Culture of Wellness observations that several Muslim colleagues lacked a place to pray and colleagues who wished to pump breastmilk were unable to find Author(s): private space to do so. Meera Sunder, MD, Kanthi Dhaduvai, MD, Andrea Gordon, Objectives: MD, Family Medicine • Appreciate the necessity and urgency of strengthening a culture POSTER 42 of wellness within residency training programs
• Describe the impact that a dedicated wellness space can have on clinic and residency employee attitudes
• Consider developing a wellness space in your residency program
Methods/Evaluation: A working group representing staff and residents was created and a small conference room was furnished and decorated for this purpose. Qualitative data was collected over the next several months regarding use of the space. 72 surveys were distributed with 77.7% response rate. Most (77%) of the respondents were aware of the space and of these 30% used the space for their wellness. 23% of the 77% of users reported to be satisfied/very satisfied with the wellness space. The space was primarily used for breastmilk pumping, praying, meditation; other less frequent purposes of use included rest, yoga and to access a box of remedies (cough drops, herbal remedies and ginger and herbal teas) located there.
Conclusion: Having a wellness space in the workplace builds morale, sense of community among its people and offers an opportunity to its users to nurture specific wellness needs. A continuous cycle of feedback driven change helps optimize the space to suit all users. This initiative definitely helped build a happier and more satisfied workforce and hopefully over time will help reduce rates of burnout among staff and residents.
HEALTH PROFESSIONS EDUCATION 53 The topics are as broad and varied as always, including case reports, formal research studies and reports on individual and population health, medical “education, innovations in patient care at CHA and quality improvement. Some are impressively artistic, others are graphic, still others almost poetic. All tell memorable stories.” – DAVID BOR, MD, CHIEF ACADEMIC OFFICER
54 QUALITY/SYSTEMS IMPROVEMENT
Practice Improvement Teams: Introduction: There is a significant shift in the way health systems are Fostering Leadership and being reimbursed, with emphasis on efficiency and clinical outcomes. Performance Improvement Understanding and properly implementing performance improvement Training Within a Clinical Practice (PI) is essential. The Malden Practice Improvement Team (PIT) is a multidisciplinary team with representation from all staff members and Author(s): is uniquely suited to learn and disseminate PI principles throughout Fa’iz Bayo-Awoyemi, MD, the clinic. Family Medicine; Dominic Wu, MD, Family Medicine; Christina Objectives: The purpose of the Malden PIT is to foster leadership Norton, Family Medicine; Lucretia skills and further knowledge of PI within the clinic. Fitzpatrick, Family Medicine; Stephen Dolat, BS, MBA, Primary Methods/Materials: Malden PIT is coached regarding facilitating Care; Susan Morrissey, BSN, effective team dynamics, collecting feedback and engaging staff. MS, Family Medicine; Gouri They also gain hands-on experience learning about PI methodologies Gupte, PhD, MHA, Performance and implementing processes using these principles. Improvement; Paola Peynetti Velasquez, MPH, Performance Results: Since the implementation of Malden PIT there has been an Improvement; Judy Fleishman, increase in PI projects that have been generated by clinic teams. Staff PhD, Family Medicine; Nicole report a better understanding of change process and have reported O’Connor, MD, Family Medicine improved team dynamics and work satisfaction through monthly ‘How’s it going’ surveys. Malden PIT members have also gained POSTER 43 leadership experiences and have taken on more leadership roles within their clinical teams and within the clinic as a whole.
Discussion/Recommendations: A multidisciplinary team that receives ongoing coaching is an effective way to teach PI methodology to the clinic in general. Central leadership is limited in its ability to communicate with the entire organization, but developing leaders within different roles and coaching them to continue PI work within their teams fosters an innovative environment where staff are engaged and feel that they are the primary drivers of change.
QUALITY/SYSTEMS IMPROVEMENT 55 Cahill 4 Unit Based Council: Cahill 4 is an inpatient, hospital-based psychiatric unit at Cambridge Transforming Care With Health Alliance. Over the past year, we have been on a journey Relationship Based Care to improve systems, maintain safety, and promote employee engagement. We decided to implement Relationship Based Care as Author(s): theoretical model focusing on three basic tenets including Care of Versa E. Belton, RN, MSN, Patient/Families, Care of Self/Co-workers and illness management/ NEC-BC recovery. The most comprehensive way to approach all the components effectively was to create a unit based council of POSTER 44 inter-disciplinary members to approach performance improvement from the most patient focused levels. We started the council and have several performance improvement projects in action that include the general categories of Safety, Patient/Family Engagement, Staff Engagement, Clinical Excellence and Education.
What Are Families Looking for Background/Problem at CHA: Primary care behavioral health in an Integrated Mental Health integration (PCBHI) in pediatrics is a vital population health Care Experience at CHA? component of Accountable Care Organizations in Massachusetts, though families are rarely involved in service design. We describe Author(s): a performance improvement initiative in child psychiatry using Nicholas Carson, MD, Psychiatry; “co-production” to improve the patient/family experience of Lee Robinson, MD, Psychiatry; integrated mental health consultation in a CHA pediatrics clinic. Traci Brooks, MD, Pediatrics; The service has a missed appointment rate of ~70%. Aileen Lorenzo, MD, Psychiatry; Brenda Marin-Rodriguez, BSc, Change Ideas/Implementation: Our multidisciplinary team (child Crimson Care Collaborative; psychiatry, psychology, and pediatrics) consulted with parent Keval Vyas, BEng, Crimson partners and used performance improvement methods to identify the Care Collaborative; Ifigenia contributing factors, intervention, and implementation affecting the Mougianis, PhD, Psychiatry patient experience. In-depth interviews with patients who received PCBHI consultation helped generate ideas for PDSA cycles. POSTER 45 Results: Interviews were conducted with seven caregivers and three young adults who received consultation. Caregivers desired more information: about the consultation service, medication responses, how to support their children, and more background information about the consultants. Some described difficulties finding mental health providers in the community and were frustrated with the short-term nature of integrated care. Young adult patients agreed that trusting the provider led to better treatment, even on sensitive topics like drug use. Both groups complained about billing and insurance difficulties.
Implications/Plan: Caregivers place a premium on receiving useful information about PCBHI even before treatment begins, while young adults value clinician behaviors that build trust. Next steps involve piloting multilingual flyers in exam rooms with practical information about integrated care and the consultants. We will measure attendance rates and satisfaction with the flyers in future PDSA cycles.
56 Reducing Avoidable ER Visits Background/Problem Statement: Patients with dementia use the in CHA House Calls Patients ED twice as often as patients without dementia. 46% of CHA’s House with Dementia Calls Program (HC) patients have dementia. Our QI project aimed to reduce ED visits by these patients. Author(s): Serena Chao, MD, MSc, Geriatrics Change Implementation: Our multidisciplinary working group, Division; Karen Finnegan, MPH, including HC and geriatric psychiatry clinicians, representatives from Institute for Community Health; Somerville Cambridge Elder Services and VNA of EM, and a volunteer Deborah Lee, MD, Medicine; whose spouse had dementia, carried out serial PDSA cycles, including: Carolyn Fisher, PhD, Institute for Community Health; Daphne • Performing chart abstractions of ED visits by HC patients Schneider, MD, Geriatrics Division with dementia.
POSTER 46 • Conducting phone interviews of family members to better understand the circumstances driving recent ED visits. We found that patients and/or their families were inconsistently contacting our HC team prior to ED visits.
• Designing a “House Calls is On Call” flyer for mass distribution.
• Referring family members to the Alzheimer’s Association (AA) to receive a targeted phone consultation from an AA memory specialist.
Outcomes: 79 HC participants had information on hospital visits from before (December 2016) and after (December 2017) the QI project. Among these patients, hospital visits declined by an average of 0.2 visits (p=0.39). Nearly one-third (31.7%) of patients had two or more hospital visits in the 12 months preceding December 2016, compared to 22.8% of patients in the 12 months preceding December 2017 (p=0.01).
Lessons Learned: Obtaining patient and family input shaped our project in ways that we did not originally anticipate. We realized that our patients and families needed more education about HC and community services that could help them manage their issues at home.
QUALITY/SYSTEMS IMPROVEMENT 57 Meaningful Wait Times: Data shows that informing patients about delays decreases the Improving the Patient Perception perception of wait time, increases the perception of quality of care, of Care and Quality Outcomes patient satisfaction, and willingness to recommend the practice, and perhaps improves colleague satisfaction. Author(s): Gilberto Gamba, MS, BSN, RN, Primary Care Nursing
POSTER 47
Decreasing Short Term Rehab Problem: A review of short term rehab utilization revealed that Utilization in a PACE Program the Elder Service Plan’s rate of short term rehab for the previous two years was above the 75th percentile for all reporting PACE Author(s): organizations. The rate had been gradually rising, reaching a peak of Mary Ann Graham, MS, RD, LDN, 1.35 days per member per month (PMPM) by quarter three of 2016. Elder Service Plan; Janet Dunphy, RN, CCM, Elder Service Plan; Objective: Decrease the number of days participants spend in short Christopher Mauro, LICSW, Elder term rehab to less than the 75th percentile for all reporting PACE Service Plan; Jonathan Burns, organizations. MD, Elder Service Plan; Jed Geyerhahn, Elder Service Plan; Tactic: A Utilization Review Committee was formed to look at Norma Malkiel, LSW, CCM, Elder reasons participants were having extended stays in short term Service Plan rehab. Guidelines were established for the team to use in monitoring participants in short term rehab. Interventions included goal setting, POSTER 48 family meetings, frequent rehab and/or medical updates. A decision tool was developed to assist team members’ decision making in sending a participant to short term rehab.
Results: The committee began to see results immediately. To date, short term utilization has been reduced by 47% in one year with an average of 0.64 days PMPM. Estimated cost savings to the program is $121,000 per month.
58 Group Wellness Classes Among Massachusetts is home to the third largest Haitian population in CHA’s Haitian Patients: Lessons the U.S., of whom one-third live in the Boston area. Data suggest Learned and Future Directions that prevalence of chronic diseases among Haitian immigrants are significant. At CHA, Haitian patients comprise 11% of the diabetes Author(s): registry despite constituting 5% of the primary care population. Anand Habib, MPhil, Harvard For over ten years, monthly wellness classes for CHA’s Haitian Medical School; Shalini Chalana, patients have been offered with an emphasis on self-management MS, MEd, RD, LDN, CDE, of chronic diseases (e.g. diabetes, hypertension, hyperlipidemia, Medicine; Arlene Katz, EdD, overweight/obesity). These classes provide a forum for participants Department of Global Health and to individually check in with medical staff regarding worrisome Social Medicine; Marie-Louise symptoms, to become better informed about their illnesses through Jean-Baptiste, MD, Medicine brief health education presentations and nutritional counseling, and to engage in group exercise. These classes have yielded two critical POSTER 49 insights. First, group classes provide an invaluable space for peer-to- peer teaching. Participants often share impromptu narratives of their illness experiences and both seek advice and provide encouragement to fellow participants. We have found that providing these perspectives and promoting this type of near-peer solidarity is more effective in spurring patients’ lifestyle changes than medical staff’s simply ‘telling’ patients to modify their diet or exercise practices. Second, in response to patients’ requests and building upon a pilot conducted in 2015, we have begun to offer culturally tailored cooking classes aimed at offering more healthful ways of preparing traditional Haitian cuisine. These well-received sessions underscore the concept that “food is medicine” and highlight the importance of collaboration with patients in designing innovations that complement traditional biomedical approaches to disease management.
QUALITY/SYSTEMS IMPROVEMENT 59 Impact of Multitiered In many institutions, preoperative screening and treatment of Interventions to Decrease asymptomatic bacteriuria (ASB) prior to joint replacement is a Routine Urine Cultures in common practice based on limited data. Recent studies have shown Asymptomatic Patients no benefit in treating ASB to decrease the rate of postoperative Undergoing Hip and joint infection (PJI). The use of unnecessary antibiotics can lead Knee Arthroplasty to increased rates of C. difficile infections, resistance, higher costs, and adverse reactions. In April 2016, the antimicrobial stewardship Author(s): team (AST) at Cambridge Health Alliance provided education to the Ebony Jackson, PharmD, orthopedic surgery department to stop this practice. In March 2017, Pharmacy; Amanda Barner, the AST successfully removed routine urine cultures (UCx) from the PharmD, BCPS, Pharmacy; elective procedure order set. Xia Thai, PharmD, Pharmacy; Lou Ann Bruno-Murtha, DO, The purpose of this project is to evaluate the impact of education Infectious Disease and the removal of UCx’s from the preoperative order set on the routine practice of screening and treatment of ASB prior to elective POSTER 50 joint arthroplasty.
This is a retrospective study of patients undergoing elective total knee or hip replacement over approximately three years, divided into three phases. Adult patients undergoing elective total hip or knee replacements were included, as well as patients undergoing elective revisions. Patients were excluded if they had documented symptoms of a urinary tract infection during the preoperative visit. The primary outcome is the number of UCx’s processed between phases two and three, compared to baseline.
Expected results include observing a decrease in the number of non-indicated UCx’s processed and a reduction in therapy for ASB. Consequently, less patients will be exposed to inappropriate antibiotic therapy and no increase in PJIs is anticipated.
60 Medication Reconciliation Clinical pharmacists in the primary care setting work closely with and Optimization by Clinical providers and patients to reconcile and optimize medication regimens. Pharmacists in the Primary Medication errors may occur with every transition of care or new Care Setting medication. This risk is heightened with polypharmacy. Medication reconciliation seeks to improve accuracy and safety of medication Author(s): regimens and promote continuity of care. Pharmacists are trained in Alexandra Kolwicz, PharmD, medication management and can identify and correct discrepancies. Pharmacy; Catrina Derderian With collaboration and resources, pharmacists may provide tailored PharmD, BCACP, Pharmacy; recommendations to optimize regimens. In addition to ensuring Emily Zouzas, PharmD, BCACP, accuracy, pharmacists ensure appropriate indications, effectiveness, Pharmacy; Monica Akus, PharmD, safety, accessibility, affordability, and proper use by patients. BCPS, DPLA, Pharmacy; Robin Heafey, PharmD, BCACP, At the CHA Cambridge Family Health and CHA Cambridge Family Pharmacy Health North centers, medication reconciliation visits are an existing, although underutilized, service. Pharmacists correct discrepancies POSTER 51 and provide tailored recommendations to providers. Through retrospective chart review, this study seeks to identify the percentage of clinical recommendations accepted by providers. Secondary outcomes include the number of discrepancies identified per patient, the number of patients transferring prescriptions to CHA pharmacies, pharmacist interventions, and provider satisfaction assessed through a survey. Prescription transfers generate revenue for CHA, may save patients money, curb polypharmacy, and improve transitions of care. The study has been approved by CHA’s Institutional Review Board. Data collection is ongoing and expected to be completed by July 1, 2018.
By magnifying the value of this service, these visits may be more frequently utilized at all CHA clinics. Also, once results are available to other institutions, this may expand pharmacist led medication reconciliation visits beyond CHA.
QUALITY/SYSTEMS IMPROVEMENT 61 HFMEA Analysis of Medication Introduction: The excellent care coordination provided by PACE Errors in a PACE Program organizations can certainly mitigate the effects of medication mismanagement so often seen in frail elders. Use of a single Author(s): pharmacy and taking advantage of blister packs can improve Lorraine Murphy, MS, RN, Quality patient safety by: & Risk Management; Mary Ann Graham, MS, RD, LDN, Elder • Reducing the chance of missed or double doses. Service Plan; Janet Dunphy, RN, CCM, Elder Service Plan; • Helping patients know whether they have taken or missed a dose. Jonathan Burns, MD, Elder Service Plan; Michelle Ortiz, RPH, • Providing a convenient alternative to opening multiple Elder Service Plan Pharmacy; medication bottles. Emerenziana D’Alleva, RPh, BCGP Problem: Despite the efforts of the Elder Service Plan, an increase in POSTER 52 the number of medication errors reported through the Cambridge Health Alliance Safety Event Reporting System (SERS) was noted.
Tactic: CHA Risk and Patient Safety Manager, CHA pharmacy staff, and ESP staff (medical director, quality manager, pharmacist, clinical manager) worked through the Healthcare Failure Modes and Effects Analysis (HFMEA) process to determine causes of medication errors (process diagram to be included in poster).
Outcome: As a result of the HFMEA analysis, two new protocols were implemented at ESP: Medication Delivery in Supportive Housing and Medication Delivery to Participants at the Cambridge Day Center. Other noted issues have been passed to CHA’s Associate Chief Pharmacy Officer for consideration.
62 Solving the Mystery of Unsatisfactory PAP smears may be reported due to low cellularity, Unsatisfactory PAP smears excessive blood or mucus. A repeat PAP smear is required to have an optimal PAP smear interpretation. Unsatisfactory PAP smears are Author(s): a source of patient anxiety and dissatisfaction, provider inefficiency, Rebecca Osgood, MD, Pathology and high laboratory costs. The Cambridge Health Alliance (CHA) and Clinical Laboratories; John Pathology Department has worked to improve the high unsatisfactory Grabbe, MD PAP smear rate at CHA which in the past has peaked at 4-5%. Nationally, the College of American Pathologists has reported POSTER 53 a 1.1% unsatisfactory PAP smear rate (50th percentile).
• In 2010, the laboratory began reprocessing and the unsatisfactory rate was reduced in the laboratory by 50%. Overall the unsatisfactory rate remained high at 3% or higher.
• In June of 2016, review of the provider specific PAP unsatisfactory rate was reviewed. Initial statistics were distributed to medical leaders to share with their providers.
• In December 2016, poor preparations were reviewed with a scientific advisor from Hologic and it was discovered that the lubricant in use was one associated with high unsatisfactory PAP smear rate.
• In April 2017 the old lubricant was removed and the approved new lubricant was in place in the CHA clinics.
Unsatisfactory PAP smears rates have plummeted from a high of 4.49% (>95th percentile) in the first half of 2016 to 1.3% (approximately 58th percentile) in the second half of 2017. Unsatisfactory PAP smear rates have been high for many years. The intervention of switching to an approved lubricant has dramatically lowered the unsatisfactory PAP smear rate to an acceptable level.
QUALITY/SYSTEMS IMPROVEMENT 63 Reducing Utilization of Unsafe 43% of CHA’s primary care patients prefer to receive care in a Practices for Communicating non-English language. It is well documented that communication with Limited English barriers can adversely affect safety and quality of care for limited Proficient Patients English proficient (LEP) patients, and that certain communication practices present more risks than others. The Institute for Community Author(s): Health (ICH) and Multicultural Affairs and Patient Services (MAPS) Ranjani Paradise, PhD, ICH; department collaborate on QI projects focused on minimizing unsafe Megan Hatch, MPH, ICH; Avlot communication practices, with emphasis on reducing utilization of Quessa, BA, JD candidate, MAPS; patients’ family members and friends as interpreters, and promoting Vonessa Costa, CoreCHI, MAPS; language testing for bilingual providers. Fernando Gargano, MAPS Project 1: Many CHA ambulatory sites utilize patients’ family POSTER 54 members and friends for more than 10% of LEP patient encounters. ICH and MAPS have worked with sites to discuss best practices and collaboratively identify opportunities for improvement. This presentation will highlight two sites where utilization of family/friends as interpreters decreased from 15-20% of LEP encounters to <10%. Successful practices at these sites could be replicated across CHA.
Project 2: CHA’s language testing program allows bilingual providers to be credentialed to communicate directly with LEP patients without an interpreter. In 2016, there were 3,370 LEP patient encounters/ month for which a provider spoke with the patient in a non-English language, and 25% of those encounters were with credentialed providers. MAPS has done intensive outreach and promotion around language testing, and the percentage of encounters with credentialed providers increased to 34% in 2017. Moving forward, MAPS and ICH will disseminate successful approaches and try new strategies to continue improving this metric.
64 Improving Access to Adult Background and Scope: The Psychiatry Department identified Outpatient Psychiatry at problems with access for patients seeking mental health services. Cambridge Health Alliance Within the MassHealth ACO, CHA will have many metrics that it must meet, including seeing inpatient discharges in an outpatient setting Author(s): within seven days of discharge, and scheduling referrals to outpatient Paola Peynetti Velazquez, MPH, psychiatry within 14 days for an appointment. Performance Improvement; Gouri Gupte, PhD, MHA, Performance Description of the Problem: Gemba walks and data showed lack Improvement; Edgardo Trejo, of data for tracking patients, duplicated referrals for different MD, Psychiatry; Lisa Foley, services, flexible processes for assignment to specialty clinics, a MPA, Psychiatry; Michael complex triage/scheduling process and low levels of transparency Williams, LICSW, Psychiatry; or standardization of schedules. Mark Albanese, MD, Psychiatry; Page Carter, LICSW, Psychiatry; Change Ideas and Implementation: Through the involvement and Julie Regner, Psychiatry; Emily participation of over 90 clinical and non-clinical staff in Primary Benedetto, MSW, LCSW, Primary Care, PCBHI, and the Department of Psychiatry, several high-level Care; Ellie Grossman, MD, Primary recommendations were made, including a single point of entry Care; Colleen O’Brien, PhD; flowing into an enhanced central intake & scheduling office with Assaad Sayah, MD, Chief Medical access to standard provider templates for the soonest appointment. Officer; Renee Kessler, MHA, Chief Operating Officer Results/Outcomes: The referral order forms and Intake Form will provide easy and accurate tracking of patients in the system. All POSTER 55 referrals are expected to be scheduled and seen promptly to meet appropriate metrics. With standardized appointment types, templates in “sessions” and transparency of schedules, capacity should increase.
Implications/Lessons Learned/Plan for Scale Up and Spread and Sustainability: The team is working with providers and leadership to implement changes to templates and scheduling, as well as with the CRO and IT to streamline patient tracking and reports for easy monitoring of clinical practices, caseload and panel management. Providers will receive training and support from the department to adjust to the new workflow. Recommendations will be piloted through a project plan for one primary care site at first in order to adjust solutions as appropriate when cascading across the system.
QUALITY/SYSTEMS IMPROVEMENT 65 Improving Access to Child and Background and Scope: The Psychiatry Department identified Adolescent Outpatient Psychiatry problems with access for patients seeking mental health services. at Cambridge Health Alliance Within the MassHealth ACO, CHA will have many metrics that it must meet, including seeing inpatient discharges in an outpatient setting Author(s): within seven days of discharge, and scheduling referrals to outpatient Paola Peynetti Velazquez, MPH, psychiatry within 14 days for an appointment. Performance Improvement; Gouri Gupte, PhD, MHA, Performance Description of the Problem: Gemba walks and data showed lack Improvement; Jacob Venter, MD, of data for tracking patients, duplicated referrals for different MBA, Psychiatry; Lisa Foley, MPA, services, flexible processes for assignment to specialty clinics, a Psychiatry; Michael Williams, complex triage/scheduling process and low levels of transparency LICSW, Psychiatry; Nicholas or standardization of schedules. Carson, MD, Psychiatry; Dianna Lesanto, LICSW; Assaad Sayah, Change Ideas and Implementation: Through the involvement and MD, Chief Medical Officer; participation of over 90 clinical and non-clinical staff in Primary Renee Kessler, MHA, Chief Care, the Department of Pediatrics and the Department of Psychiatry, Operating Officer several high-level recommendations were made, including a single point of entry flowing into an enhanced central intake & POSTER 56 scheduling office with access to standard provider templates for the soonest appointment.
Results/Outcomes: The referral order forms and Intake Form will provide easy and accurate tracking of patients in the system. All referrals are expected to be scheduled and seen promptly to meet appropriate metrics. With standardized appointment types, templates in “sessions” and transparency of schedules, capacity should increase.
Implications/Lessons Learned/Plan for Scale Up and Spread, and Sustainability: The team is working with providers and practice managers to implement changes to templates and scheduling, as well as with the CRO and IT to streamline patient tracking and reports for easy monitoring of clinical practices, caseload, and panel management. Providers will receive training and support from the department to adjust to the new workflow. Recommendations will be piloted through a project plan for one primary care site at first in order to adjust these solutions as appropriate when cascading across the system.
66 Improving the Phone Menu Across Background: A problem of patients accessing primary care and Cambridge Health Alliance various specialities over the phone was identified.
Author(s): Description of the Problem in Context at CHA: Gemba walks and data Paola Peynetti Velazquez, MPH, showed long phone tree, 90% of the callers selected English, patient Performance Improvement; satisfaction with the phone system were low, and there was variability Gouri Gupte, PhD, MHA, in abandonment rate. Our review of the inefficiencies included no Performance Improvement; option to return to the menu, line getting disconnected, and invalid Fernando Gargano, Multicultural options selected. Affairs and Patient Services; MaryAnn Heuston, MA, Revenue Change Ideas and Implementation: The script was reviewed and Cycle Access Operations; Avlot redesigned to be simple, standardized, and patient friendly. Quessa, Multicultural Affairs and Patient Services; Vonessa Results/Outcomes: The options reduced (including languages), Costa, Multicultural Affairs and resulting in lower abandonment rates and wait times, and improved Patient Services; Paola Held, patient feedback. Calls not appropriate for the clinic option were MEd, Revenue Cycle Operations; reduced, opening lines for those patients in need of scheduling Steven Dolat, MBA, Primary Care appointments. Operations; Patrick Wardell, MBA, Chief Executive Officer; Implications/Lessons Learned/Plan for Scale Up and Spread and Renee Kessler, MHA, Chief Sustainability: Pilot tests were performed in primary care and then Operating Officer confirmed with specialties. From early March 2018, all phone menus across most specialities and all primary care sites at CHA will be POSTER 57 changed consistently.
Implementing Addiction According to the CDC, opioids both prescribed and illicit are the Services Into Primary Care main drivers of overdose deaths. Opioid overdoses have quadrupled since 1999. 91 Americans die daily from opioid overdoses, and Author(s): Massachusetts is part of those numbers. MA Department of Public Debralee Quinn, MSN, RN-BC, Health reported in 2016, 2,190 patients died of opioid related CNN, CH-GCN, CCM, Primary Care overdoses in MA.
POSTER 58 According to CDC, Drug overdose is the leading cause of accidental death in the US, with 64,000 lethal drug overdoses in 2016. It has almost doubled in a decade.
Opioid use is a chronic illness and often difficult to treat. Since there is a lack of treatment centers to meet the crisis CHA has taken a holistic approach to meet patients needs and incorporate in primary care. This has required making new positions, meeting grant needs and continued adjustments as this new paradigm is implemented.
QUALITY/SYSTEMS IMPROVEMENT 67 Improving the Mammography Background: The Radiology Department identified problems Workflow in the Radiology with getting patients through the unit and delays in completing Department at Cambridge mammograms during the appointment time. A multidisciplinary team Health Alliance was created with radiologists, technologists and administrative staff.
Author(s): Problem Statement: Gemba walks showed that ultrasounds took Aliysa Rajwani, BDS, MPH; longer than the scheduled time and caused backlogs that affected Gouri Gupte, PhD, MHA; Mary workflow for screening mammograms and also led to increased Kearns, RN, Quality Management; patient wait times. Patient delays also affected the schedule Leah Harrington; Hetal Verma, and workflow. Quantitative data collected during observational MD; Doris Gently; Carol Hulka, studies and analyzing the current schedule demonstrated that the MD, Radiology room utilization of the ultrasound room was equal to that of the mammography screening rooms in spite of fewer appointments. POSTER 59 Data showed a high variation in patient wait times and cycle time.
Change Ideas: The team identified inefficiencies such as short ultrasound appointment slots, schedule not including quality check (QC) time and lack of patient delay policies that affected daily workflow. The team focused efforts on increasing the ultrasound appointment time slot to prevent future backlogs and also included QC time as part of the current schedule. Additionally, some patient delay policies were implemented in order to ensure that the patient arrived in advance of their scheduled appointment.
Results: Success metrics include patient and staff satisfaction, reduced lead time (includes wait time and other non value added time) per patient and increase in number of screening mammograms.
Implications: The optimization of the workflow and schedule improved patient access in the unit. Next steps could be to ensure that the unit is utilized to its complete capacity.
68 Colorectal Cancer at CHA: Introduction: Given the socioeconomic, substance abuse, and mental 10-Year Comparison of CHA health disparities in CHA’s patient population, we queried whether with National Cancer DataBase Colorectal Cancer patients at CHA may present at advanced stage (NCDB) and an In-Depth Review or have delays in their cancer diagnosis and treatment. of 2016 CHA Colorectal Patients Methods: Using the NCDB from 2006-2015, we compared the stage Author(s): at presentation for CHA patients with all other colorectal patients in Heidi Rayala, MD, PhD, Surgery; the United States. In addition, a retrospective review of all patients Mary Kearns, Quality & Patient diagnosed with colorectal cancer at CHA in 2016 was performed, Safety; Richard Swanson, MD, collecting information on presenting symptom, colonoscopy history, FACS, Surgery treatment history, and barriers to care. We defined delay in care as more than a 30-day lapse between decision points. POSTER 60 Results: 20.2% of CHA patients presented with Stage IV colon cancer, compared to 21.9% in the remaining US. Of the 36 patients diagnosed with colorectal cancer at CHA in 2016, 23% of patients at CHA were captured by screening colonoscopy, compared with 10.7% of US patients reported in the literature. Of the 25% of our patients that had a barrier to care, only two patients actually had a delay to treatment, and both were due to physical comorbidities rather than social barriers. Delay in treatment occurred in 11/31 (35%) of patients, with median delay of 42 days. Delays were more common between GI consult visit and diagnostic colonoscopy, which likely reflects an effort at continuity of care.
Discussion: When compared to national data, CHA patients are more likely to be diagnosed by screening, do not present at advanced stage, and have minimal delays in care.
QUALITY/SYSTEMS IMPROVEMENT 69 A Quality Improvement Project: Screening, Brief Intervention, and Referral to Treatment (SBIRT) is Better Substance Use Screening newly mandated by the state of Massachusetts. In early 2017, the for Cambridge Students Cambridge Public Health Department screened all 9th grade students at Cambridge Rindge and Latin High School (CRLS) for the first time. Author(s): Although the screening was completed successfully, improvements Tali Schiller, MPH, Cambridge could be made to the process that would lessen strain on staff, Public Health Department; Kristin improve the quality of the intervention, and ensure a smooth Ward, MPH, Cambridge Public hand-off between implementation teams. Health Department; Tracy Rose- Tynes, BSN, RN, Cambridge Using the five categories defined by root cause analysis, the quality Public Health Department; Mary improvement team came up with 13 potential actions. These were Kowalczuk, MSW, Cambridge winnowed down using an Impact/Effort Plot to eight strategies Public Health Department for improving SBIRT screening. Theoretically, focusing on process improvements (such as logistics and standardization) would lessen POSTER 61 strain on staff, improve the quality of the intervention, and ensure a higher percentage of completion.
In 2018, the screening process was overseen by CRLS school administration for the first time. Due to the change in leadership of the screening, four out of eight proposed strategies were implemented for the screening. After evaluation, performance metrics did not reach the previously defined goal for success. However, the systemic improvement strategies that were implemented led to a smoother hand-off to school administration, who will be conducting all future screenings.
This creates an opportunity for continuous quality improvement in years to come. We hope to build in 2019 by implementing all eight improvement strategies, collecting performance metrics, and completing a PDCA cycle in partnership with school administration.
70 CHA Broadway Health Care Background: Health Care Proxy (HCP) is an important metric in Proxy Improvement Project: maintaining NCQA Level 3 recognition as a Patient Centered Medical A Multi-Layered Approach Home. In November 2016, only 24.91% of patients at Somerville Adult Medicine had a HCP on file, by far the lowest percentage of all the Author(s): CHA sites. A project was undertaken at that time by the Practice Arshiya Seth, Medicine; Maria Improvement Team at the CHA Broadway Care Center to increase Terra, Medicine; Priyanka Anand, the percentage of completed HCP’s to 75% by June 2018 to become Performance Improvement; more in line with the CHA-wide average. Jesenia Bermudez, Broadway Care Center; Rina Bernardez, Methods: Broadway Care Center; Betsy Doucette, Broadway Care Center; 1. Gemba walks—Mapped current workflow and identified Wilkerson Elysee, Broadway inconsistencies and areas for improvement. New workflow Care Center; Meredith Jones, designed to overcome inconsistencies. Broadway Care Center; Dierdre Jordan, Broadway Care Center; 2. Reviewed sample of completed HCP forms: revealed that the Denise Leite Alves, Broadway form’s layout resulted in errors. Care Center; Mary Saginario; Robert Smith, LPN, Broadway 3. Consulted with CHA attorney to improve user friendliness of HCP Care Center; Maria Sousa form; led to drafting of a new form.
POSTER 62 4. Plan-Do-Study-Act cycle with revised form: concluded that it was easier to complete, introducing less errors.
5. Introduced updated HCP workflow and new form at all-staff meeting. MA coaching and role-playing to highlight best practices.
6. Compared scanned HCP in medical records vs. orders signed in EPIC; corrected errors.
Outcomes:
1. New HCP form adopted across CHA network.
2. Established a new workflow, allowing MA’s to sign HCP orders.
3. Increased awareness and comfort level among staff at site in dealing with HCP.
4. Increased completed HCP’s from 24.91% (November 2016) to 52.44% (March 2018).
Lessons learned:
1. Layered involvement of staff and patients led to opportunities for all-around contribution to increase HCP numbers.
2. Importance of MA being able to sign HCP orders.
QUALITY/SYSTEMS IMPROVEMENT 71 Planning Together: Care Planning Health disparities faced by adults with serious mental illnesses to Improve Patient Activation (SMI) are well-documented and widely accepted estimates are that and Health Outcomes Americans with schizophrenia die 20-30 years younger than the general population. Efforts to address this disparity have thus far Author(s): tended to focus at the level of the health system, including improving Miriam Tepper, Psychiatry; care access, providing care management, and improving care quality. Ekta Taneja, Psychiatry; Despite these efforts, the mortality gap for adults with SMI appears to Alexander Cohen, Psychiatry; be increasing with time. Martha Barbone Behavior change literature suggests patients will be unable to POSTER 63 utilize health promotion interventions if they lack a sense of self- efficacy about making behavior changes. Patient activation, defined as having the knowledge, skills, and confidence to make a change, provides a critical link between what health systems offer and patient responsiveness to these interventions. Improving patient activation has the potential to increase the efficacy of ongoing efforts to address the health disparities faced by adults with SMI.
This quality improvement initiative investigated whether use of the patient-centered care plan, which is a tool embedded in the EHR in which patients articulate their health goals, could increase patient activation. In addition to quantitative data on care plan completion, qualitative data was obtained from interviews with five patient- provider dyads. Key elements of the intervention included sequential discussions with clinical team, involvement of a peer provider, use of design tools, and bringing qualitative findings back to team. The care plan tool shows promise as a means of helping clinician/patient dyads focus on activation as a step toward improving health outcomes.
72 Cost-Savings of Long-Acting Long acting antipsychotic injections (LAIs) play an important role Antipsychotic Injections in a in improving patient adherence, but are expensive medications and Transitional Outpatient Clinic not reimbursed in a hospital setting. The cost of LAIs at Cambridge Upon Hospital Discharge Health Alliance (CHA) during fiscal year 2017 on the inpatient psychiatry units was greater than $150,000. The purpose of this Author(s): project is to provide patient access to these important medications Rebecca Tourtellotte, PharmD, while remaining fiscally responsible as an organization. Pharmacy; Jessica Goren, PharmD, BCPP, Pharmacy The primary objective of this project is to analyze the cost savings associated with administering LAIs at an outpatient transitional POSTER 64 clinic on the day of discharge. Revenue created for the outpatient pharmacy and the net income for the organization will also be evaluated. Additional outcomes include the percentage of patients that receive LAIs in the transitional clinic at discharge, the rate of follow up for second injections, and adherence to clinic visits within 7 days of discharge in the patients followed by CHA’s outpatient psychiatry clinics.
Transitional clinics are currently established at both CHA Cambridge and Everett Hospitals. A new workflow for the discharge process is in development. Patients will be escorted to the transitional clinic upon discharge from the psychiatric unit and the LAI supplied by the CHA’s outpatient pharmacy will be administered. Medications from the pharmacy will be billed and reimbursed through the patient’s insurance as an outpatient medication which will increase revenue for the pharmacy. This workflow will help lower costs for the inpatient pharmacy, increase revenue for the outpatient pharmacy, and potentially increase profit for the organization.
QUALITY/SYSTEMS IMPROVEMENT 73 An Interdisciplinary Background: Efficient clinic flow is essential in a clinic serving a Practice Improvement Team: diverse, underserved patient population which frequently requires Clinic Workflow Design multidisciplinary care and care coordination. An interdisciplinary Practice Improvement Team (PIT) creates a collaborative atmosphere Author(s): with interdisciplinary representation from the healthcare team to Dominic Wu, MD, Family address issues in clinic flow. Medicine; Fa’iz Bayo-Awoyemi, MD, Family Medicine; Gouri Description of the problem in context at CHA: Mean clinic times Gupte, PhD, MHA, Performance for CHA Malden patients were collected from January - May 2017 Improvement; Paola Peynetti (n=632). The data was collected by manual “time-in” and “time-out” Velasquez, MPH, Performance of providers during de-identified patient visits. This baseline data Improvement; Christina Norton, revealed that many inefficiencies in workflow were due to delays in Family Medicine; Lucretia transitions of care between members of the care team from front Fitzpatrick, Family Medicine; desk staff to providers. Rumel Mahmood, MA, MS, Business Data Analysis; Susan Change Ideas and Implementation: With input from the clinic staff, Morrissey, BSN, MS, Family ideas for increasing efficiency were gathered to design a clinic Medicine; Stephen Dolat, BS, workflow, focusing first on patient rooming. MBA, Primary Care; Lora Council, MD, MPH, Primary Care; Jill Batty, Outcomes: A 42-item workflow for patient rooming was designed BS, MHA, Finance; Jessica Knapp, by the PIT with support from CHA central leadership. The workflow DO, CAQSM, Family Medicine; included pathways for visit preparation, rooming process, and after Judy Fleishman, PhD, Family visit steps with the patient (including complex care management/ Medicine; Nicole O’Connor, MD, social work, behavioral health, nursing care). Family Medicine Implications: This workflow was piloted over a two-month process POSTER 65 including shadowing and ongoing bidirectional feedback. Data collection is ongoing regarding post-intervention clinic times for patients to compare to the baseline data. Future interventions include front desk workflow design & implementation. Through this project, the clinic staff and particularly the PIT have developed practice improvement and leadership skills they can use to inform their future work and improve clinical practice.
74 Can We Improve Provider Background: Provider disengagement increases costs, decreases Engagement Through patient satisfaction, and reduces quality of care. Cambridge Health Co-Production? Alliance’s strategic priority is to make CHA a great place to work.
Author(s): Problem: In a 2016 survey, provider engagement at CHA was in the Leah Zallman, Bree Dallinga, 6th percentile nationwide. Joy Curtis, Marcy Lidman, David Porell, Assaad Sayah on behalf Change Ideas and Implementation: Using a co-productive lens, of the Provider Engagement CHA implemented a series of changes with iterative plan-do-study- Steering Committee act cycles. First, it created the Provider Engagement Steering Committee (PESC), an interdisciplinary and cross-departmental team POSTER 66 of providers and leaders charged with advising the organization on a strategy for provider engagement. This committee works with operational leaders, the Chief’s Council, and the Medical Executive Committee to develop strategies for change. Second, CHA appointed two provider leads for provider engagement to lead the committee. Third, CHA implemented a series of pilots including executive leader rounds, virtual office hours, stay interviews, peer mentoring and the Providers’ Corner quarterly newsletter.
Outcomes: The PESC has met monthly with operational leaders and provided input on operational issues that affect provider engagement. Executive leader rounds were positively rated by providers. Voluntary CHA Providers Organization 12-month rolling turnover decreased from a median of 10% to 7%.
Lessons Learned: A group of providers and leaders can support provider engagement strategies. Pilots and the structure of the PESC are undergoing continual evaluation to maximally support the ongoing need for provider engagement strategies at CHA.
QUALITY/SYSTEMS IMPROVEMENT 75 Impact of Medical Scribes on Introduction: Medical scribes are a clinical innovation increasingly Productivity, Face-to-Face Time being used in primary care, but their impact remains unclear. and Patient Comfort with Scribes in Primary Care Objectives: To examine the impact of medical scribes on productivity, time spent facing the patient during the visit, and patient comfort Author(s): with scribes in primary care. Leah Zallman, MD, MPH, Institute for Community Health; Karen Methods: Prospective observational pre-post study of five family and Finnegan, MPH, Institute for internal medicine physicians and their patients at an urban safety Community Health; David Roll, net health clinic. We examined productivity using EMR data on the MD, Medicine; Martina Todaro, number of patients seen and relative value units (RVUs) per hour. MA, Institute for Community We directly observed clinical encounters to measure the amount Health; Rawan Oneiz, MD; of time providers spent facing patients and other cycle components. Assaad Sayah, MD, Chief We queried patient comfort with scribes using surveys administered Medical Officer after the visit.
POSTER 67 Results: RVUs/hour increased by 10.5% from 2.59 pre-scribe to 2.86 post-scribe (p <0.001). Patients/hour increased by 8.8% from 1.82 to 1.98 (p <0.001). RVUs/patient did not change. After scribe implementation, time spent facing the patient increased by 57% (p<0.001) and time spent facing the computer decreased by 27% (p=0.003). The proportion of the visit time that was spent face to face increased by 39% (p<0.001). Most (69%) patients reported feeling very comfortable with the scribe in the room, while the proportion feeling very comfortable with the number of people in the room decreased from 93% to 66% (p<0.001).
Conclusions: While the full implications of medical scribe implementation remain to be seen, this initial study highlights the promising opportunity of medical scribe implementation in primary care.
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